19th COCHRANE COLLOQUIUM Sustainable Evidence-Based Health Care in Times of Crisis Madrid October 19-22 . 2011 - PowerPoint PPT Presentation

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19th COCHRANE COLLOQUIUM Sustainable Evidence-Based Health Care in Times of Crisis Madrid October 19-22 . 2011

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Title: 19th COCHRANE COLLOQUIUM Sustainable Evidence-Based Health Care in Times of Crisis Madrid October 19-22 . 2011


1
19th COCHRANE COLLOQUIUMSustainable
Evidence-Based Health Care in Times of Crisis
Madrid October 19-22 . 2011
  • 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.
9,1 - 10,5
4,5 - 6,0
6,1 - 7,5
7,5 - 9,0
10,6 - 12,0
3
Massive Demand
Medical consultations/capita. Europe. 2003
9.5
5.9
2.5
European Countries
Ecosalud. OCDE 2005.
4
Fragmentation
5
THIS IS THE RESULT ACROSS THE CONTINUUM !
6
Primary Prevention
Early Management
Acute Management
Rehabilitation secondary prevention
7
  • Having everything under the same
  • roof does not guarantee clinical
  • integration nor a tidy operation
  • across the disease continuum R. Bengoa

Primary Prevention
Early Management
Acute Management
Rehabilitation secondary prevention
8
Primary Prevention
Early Management
Acute Management
Rehabilitation secondary prevention
Downstream
Upstream
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
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
  • THAT FRAGMENTATION
  • CANNOT PROVIDE
  • A SUSTAINIBLE HEALTH SYSTEM

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
(No Transcript)
13
WHAT ARE WE TRYING TO DO ?

TRYING TO FIT IN SOME OF THOSE MANAGEMENT
PROCESSES IN .
14
Using frameworks/models
15
Some sort of structured patient education both
direct and remote
REMOTE PATIENT EDUCATION
PATIENT EDUCATION
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
Telecare /Telemedicine
Diabetic retinopathy
18
  • What results are some
  • organizations getting?
  • Is the Evidence Growing?

19
Community Care North Carolina (CCNC)
  • Health programme for
  • Low-income adults and their children and
    dishabilities (880.000 habitants)
  • 3000 physicians
  • Objective
  • Improve the quality, cost, accesibility and
    utilisation of services for Medicaid recipients
  • Methods to promote integration
  • Locally adapted clinical guidelines
  • Case management services
  • Financial incentives
  • Data review and analysis
  • Feedback on clinical practice

Source http//www.communitycarenc.org/our-results
/
20
Integrated cardiovascular care
...is leading to reductions in heart attacks and
strokes.
Stoke-related Hospitalization Rates in No.
Cal.1998-2007
ST Elevated MIs in No. Cal. 1998-2007
Age and sex adjusted rate per 1,000
Age and sex adjusted rate per 1,000
KP Northern California ALL program, PHASE,
results.
17
21
VA Continues to Exceed HEDIS in 2008
INDICATOR VA 2008 VA 2007 Commercial 2007 Medicare 2007 Medicaid 2007
Breast cancer screening 87 86 69 67 50
Cervical cancer screening 92 91 82 n/a 65
Colorectal cancer screening 79 78 56 50 n/a
LDL Cholesterol lt 100 after AMI, PTCA, CABG 66 62 59 56 38
Diabetes DM control HbA1c lt 9.0 84 84 71 71 52
Diabetes LDL-Clt100 68 64 44 47 31
Diabetes Eye Exam 86 85 55 63 50
Diabetes Renal Exam 93 91 81 86 74
Diabetes BP lt 140/90 78 77 64 59 56
Hypertension BP lt 140/90 75 76 62 58 53
Smoking Cessation Counseling (3) 89 83 76 n/a 70
Smoking Medications offered(3) 84 n/a 51 n/a 39
Smoking Referral/strategies (3) 92 n/a 48 n/a 39
Immunizations influenza 84 72 49 72  
Immunizations pneumococcal 94 90 n/a 67  
22
  • Why ? Because the Evidence is Increasing
  • Estimated 3.7 million net savings for a ROI of gt
    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
Building some sort of Local Health System
Aim LINK several lines of work which tend to
operate separately
  • 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

24
DIFFERENT COUNTRIES/SYSTEMS MOVING IN THE SAME
DIRECTION
Mid-term policy perspective/ trend
  • 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

25
Trend Taking Shape In Normative Policy
Interventions
  • 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..

26
How are we moving forward in the Basque
Country ?
27
ObjectiveSimultaneously 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
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

IN THE BASQUE COUNTRY THE MAIN NARRATIVE IS
CHRONIC DISEASES AND CLINICAL INTEGRATION
R. Bengoa
29

Launch interventions in a coherent package Many
levers simultaneously
Competencias Avanzadas Enfermería Formar a 300
enfermeras en los nuevos roles hasta 2013
Colaboración sociosanitaria 4 municipios con
funcionamiento integrado, 1 hospital con plan de
altas con prevención de dependencia, 1 unidad de
ortogeriatría
Financiación y Contratación Implantación plena de
un sistema de asignación financiera territorial
ajustada por riesgo
R. Bengoa
30
Examples bottom up Organizational Innovation
DIFFERENT MODELS OF INTEGRATED CARE ORGANISATIONS
(systems)
Non Integrated organizational structure
Integrated organizational structure
Osi Bidasoa
H. Basurto- C-Bilbao-H. Santa marina
  • 384.000 habitants
  • 24 primary care centers
  • 1 acute hospital
  • 1 medium and long term hospital
  • 85.000 habitants
  • First integrated organizational structure
    (hospital and primary care center)

31
This Should Look Better At The Next LSN
Meeting!!!!
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
SCALABILITY
  • 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
34
  • Thank you
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