Title: What is a High Performing Health Care System and What are the Policies and Practices to Get There
1What 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
2Primary Care Doctor and Medical Home
3Adults 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
4Regular 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
5Difficulty 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
6Coordination 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
7Doctor 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
8After 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
9Chronically 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
10Quality 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
11Primary Care Capacity to Manage Chronic Illness
12Characteristics of 2007 Survey Participants With
Chronic Conditions
Source 2007 Commonwealth Fund International
Health Policy Survey
13Regular 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.
14Specialist Care Coordination
Base Adults with a chronic condition who saw a
specialist in the last year
Source 2007 Commonwealth Fund International
Health Policy Survey
15Received 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
16Doctors 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
17Doctor Gives You Plan for Self-Management
Base Adults with a chronic condition
Percent
Source 2007 Commonwealth Fund International
Health Policy Survey
18Primary Care Practices With Financial Incentives
to Manage Patients With Chronic Conditions
Percent
Source 2006 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians
19Primary 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
20Learning from Abroad International Examples of
Initiatives to Improve Health Care System
Performance
21The 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
22German 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
23Veterans 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
24After-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
25Virtual 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
26Country 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
27National 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
28Conclusions
- 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
29Acknowledgements
With great appreciation to Meghan Bishop, Cathy
Schoen, Karen Davis, Stephen C. Schoenbaum, and
Melinda K. Abrams for their contributions to this
presentation