What is a High Performing Health Care System and What are the Policies and Practices to Get There

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What is a High Performing Health Care System and
What are the Policies and Practices to Get There?

• International Forum on Quality and
• Safety in Health Care
• April 24, 2008
• Robin Osborn
• Vice President and Director
• International Program in Health Policy
• The Commonwealth Fund

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Primary Care Doctor and Medical Home
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Adults Across Countries Place High Value on
Having A "Medical Home"
When you need care, how important is it that you
have one practice/clinic where doctors and nurses
know, provide and coordinate the care that you
need?
Percent responding very/somewhat important
Source 2007 Commonwealth Fund International
Health Policy Survey
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Regular Doctor Compared to Having a Medical Home
Percent
Note Medical Home includes having a regular
provider that knows your medical history, is easy
to contact, and coordinates your care. Source
2007 Commonwealth Fund International Health
Policy Survey
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Difficulty Getting Care on Nights, Weekends,
Holidays Without Going to the ER, by Medical Home
Percent reported very/somewhat difficult
Note Medical Home includes having a regular
provider that knows your medical history, is easy
to contact, and coordinates your care. Source
2007 Commonwealth Fund International Health
Policy Survey
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Coordination Problems Medical Records Not
Available During Visit or Duplicative Tests, by
Medical Home
Percent with coordination problems
Note Medical Home includes having a regular
provider that knows your medical history, is easy
to contact, and coordinates your care. Source
2007 Commonwealth Fund International Health
Policy Survey
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Doctor Always Explains Things, Spends Enough Time
With You, and Involves You in Decisions, by
Medical Home
Average percent of adults with a regular doctor
or place of care reporting always across three
indicators of doctor-patient communication
Note Medical Home includes having a regular
provider that knows your medical history, is easy
to contact, and coordinates your care. Source
2007 Commonwealth Fund International Health
Policy Survey
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After Emergency Room Use, Did Regular Doctor Seem
Informed About Care Received? By Medical Home
Percent yes
Note Medical Home includes having a regular
provider that knows your medical history, is easy
to contact, and coordinates your care. Source
2007 Commonwealth Fund International Health
Policy Survey
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Chronically Ill Patients Reporting An Error, by
Medical Home
Base Has a chronic condition
Percent reporting any medical, medication or lab
error
Note Medical Home includes having a regular
provider that knows your medical history, is easy
to contact, and coordinates your care. Source
2007 Commonwealth Fund International Health
Policy Survey
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Quality of Care from Doctor, by Medical Home
Percent rated care received excellent or very
good
Note Medical Home includes having a regular
provider that knows your medical history, is easy
to contact, and coordinates your care. Source
2007 Commonwealth Fund International Health
Policy Survey
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Primary Care Capacity to Manage Chronic Illness
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Characteristics of 2007 Survey Participants With
Chronic Conditions
Source 2007 Commonwealth Fund International
Health Policy Survey
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Regular Doctor Coordinates Care Received from
Other Doctors and Places
Base Adults with a chronic condition and regular
doctor/place
Percent responding always
Source 2007 Commonwealth Fund International
Health Policy Survey.
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Specialist Care Coordination
Base Adults with a chronic condition who saw a
specialist in the last year
Source 2007 Commonwealth Fund International
Health Policy Survey
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Received Conflicting Information from Different
Doctors, Nurses, or Other Health Professionals
Base Adults with a chronic condition Percent
reporting often/sometimes
Source 2007 Commonwealth Fund International
Health Policy Survey
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Doctors Office Has a Nurse or Other Professional
Regularly Involved in Care Management
Base Adults with a chronic condition
Percent
Source 2007 Commonwealth Fund International
Health Policy Survey
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Doctor Gives You Plan for Self-Management
Base Adults with a chronic condition
Percent
Source 2007 Commonwealth Fund International
Health Policy Survey
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Primary Care Practices With Financial Incentives
to Manage Patients With Chronic Conditions
Percent
Source 2006 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians
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Primary Care Practice Capacity to Generate
Patient Information
Percent of primary care practices reporting easy
to generate
Source 2006 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians
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Learning from Abroad International Examples of
Initiatives to Improve Health Care System
Performance
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The Esther Project in Sweden
Esther is an 88 year old, ailing, but competent
Swedish woman with heart failure who lives alone
on the third floor and cannot get down the
stairs

• Whats best for Esther Aim to improve patient
  flow through the system and strengthen
  coordination/communication among providers
• Created fictitious but prototypical patient
  scenarios to understand interactions with health
  care system from the patients perspective
• Solicited patient and provider experiences
• Worked with a multidisciplinary team and tested
  whether elderly persons with certain clinical
  profiles (e.g. Esthers with colon cancer,
  dementia, etc.) could count on good care and
  services
• Established a network of 250 providers trained in
  the projects goals and processes
• Examples of Impact
• Redesigned processes of care, e.g. access to
  specialists, multidisciplinary teams, open access
  scheduling
• Better medication management

Reference Pursuing Perfection Initiative
launched by the Robert Wood Johnson Foundation
with the Institute for Health Care Improvement
(IHI) as the national program office
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German Integrated Care Models
Bundled payment and integrated team-care for
cancer, following evidenced based guidelines.
Center for Integrated Oncology in Cologne with
Barmer and AOK Sickness Funds.

• Annual fixed global fee based on disease-specific
  and clinical stage
• Fee includes diagnostics, surgery, radiotherapy,
  chemotherapy, follow-up and palliative care
  Extra payments for outliers
• Detailed treatment pathways and evidence-based
  guidelines
• Cancer-specific quality indicators
• Interdisciplinary tumor board, oncology care
  groups, and consultation hours
• Responsibility clearly assigned to hospital and
  office-based programs
• Use of a Patient Navigator as a permanent
  contact person
• University Hospital Cologne and network of 100
  office-based physicians
• Goals
• Highest possible quality of care
• Economic efficiency

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Veterans Administration Model for Care
Coordination
Care Coordination/Home Telehealth (CCHT) model
targets patients with diabetes, chronic heart
failure, hypertension, depression, and chronic
obstructive pulmonary disease

• Key features
• Computerized patient record is central to the
  concept
• Care Coordinator nurse or social workers
• National curriculum and national training center
  for care coordinators
• Use of home telehealth technologies to monitor
  vital signs and disease management data
• Continuous dataset for managing patients to
  trigger interventions - telephone calls, home
  visits, clinic appointments, or urgent hospital
  admissions
• Strong element of patient self-management
• Pilot Study Results showed
• High level of patient satisfaction
• Cost savings from reduced hospitalizations
• Cost savings from reduced emergency room use

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After-Hours Care Community Approaches

• Netherlands
• Large-scale after-hours primary care cooperatives
• Nurse telephone triage and advice with back-up by
  physician, walk-in visits and house calls
• Evidence-based triage protocols and guidelines
• Preliminary impacts for advanced model integrated
  with ER
• 25 increase in primary care contact
• 53 reduction in contacts with emergency services
• 12 reduction in ambulance calls
• Denmark
• Country-wide cooperatives operated by physicians
• Family physician telephone triage and advice,
  walk-in visits and house calls
• Electronic access to patients medical records to
  enable coordination of care
• Impacts
• Increase in telephone consultations and decrease
  in house calls
• Reduced physician workload

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Virtual Wards in the NHS
Aim Enable elderly with multiple chronic
conditions to be managed in their homes

• Use of predictive risk modeling to target
  patients at greatest risk of emergency
  hospitalization
• Shared electronic medical record with full GP
  record downloaded
• Home assessment by a nurse, including social,
  medical, and physical limitations
• Multidisciplinary team led by a nurse (Community
  Matron) meets daily
• Single point of contact is used by patients,
  staff, ER, after-hours services to ensure
  coordination
• Every night, email list of all virtual ward
  patients is shared with local hospitals, NHS
  Direct, and after-hours GP services
• Daily/weekly/monthly patient teleconference,
  depending on patient needs
• Community matron provides continuity can go to
  patients appointments with them, sit in on
  consultations, help plan hospital discharges
• Currently 10 virtual wards with 1,000 patients

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Country Initiatives

• Incentives for Quality Improvement
• U.K. GP Contract
• New Zealand Primary Health Organizations
• Australia Practice Incentives Program
  reimbursement for coordination of care,
  multidisciplinary teams and nurse support
• Germany Global fees, Statutory Disease
  Management Programs
• Sweden Co-location of services expanded use of
  nurses
• Netherlands Support for nurses on primary care
  team
• Transparency
• Germany National Hospital Quality Benchmarking
• Denmark National Quality Indicator Project
• Information Technology and Electronic Medical
  Records
• U.K. Connecting for Health
• Canada Health Infoway
• Germany and Australia Electronic, portable
  personal health records
• Denmark National HIT and exchange

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National Policy Towards A High Performing Health
Care System

• Case Study of England
• Clinical and Waiting Times Targets
• Star ratings and Foundation Hospitals
• Breakthrough Collaboratives
• National Institute for Clinical Excellence
• Commission for Health Care Improvement
• National Patient Safety Agency
• Connecting for Health
• National Service Frameworks
• NHS Direct
• Quality and Outcomes Framework
• National Institute for Innovation

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Conclusions

• Variations in health system performance offer
  opportunities for cross-national learning
• Experiences in all countries indicate the need
  for more integrated, patient-centered care
  systems
• Having a Medical Home improves patient
  experiences
• EMRs support systemness, integration, and the
  flow of information with the patient
• Incentives need to be better aligned for quality
  and efficiency
• Three major challenges
• Better coordination of care
• New approaches to managing patients with complex
  chronic illnesses
• Primary care redesign and workforce strategy
• Changes in policy and practice are essential to
  achieving a high performance health care system

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Acknowledgements
With great appreciation to Meghan Bishop, Cathy
Schoen, Karen Davis, Stephen C. Schoenbaum, and
Melinda K. Abrams for their contributions to this
presentation