Dr Marc Bruijnzeels Directeur Jan van Es Instituut 'Wat kunnen we leren uit de (Nederlandse) praktijkvoorbeelden van geïntegreerde zorg?‘ Van ideaal naar praktijk Dr Marc Bruijnzeels Directeur Jan van Es Instituut

Redenen waarom huidige inrichting niet voldoet? Rationele maatschappelijke belangen en de rationale individuele belangen zijn in conflict met elkaar! Enige barrières: Nieuwe technologieën met té weinig impact; physician-centric care; En te weinig waardering en gebruik van de aanwezige systeemkennis bij clinici en organisaties De zorgkosten stijgen gem. met 4% per jaar, terwijl het inkomen met 1,75% stijgt. Bij ongewijzigd beleid gaat in 2040 45% van het modaal inkomen op aan zorgkosten. T.a.v. 23% in 2011. Dat maakt zorg in een keer een zéér maatschappelijk vraagstuk! Bron: Berwick 2008

Fundamentals van de Triple Aim

Triple Aim in de pilootprojecten Plus equity Eén interafhankelijke doelstelling Doelstellingen in balans

Not all persons have the same need for health care % of Population % of Resources 1% 30% 10% 72% 50% 97%

Co-morbidity is the norm among older adults Source: Partnership for Solutions, Johns Hopkins University

Physical and mental comorbidity is associated with SES PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’ Source: Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet, Volume 380, Issue 9836, Pages 37-43. Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie

To cope with these developments we need a paradigm shift from cure to care. Instead of being reactive and wait until a health problem arise, the public must be stimulated to prevent healthcare problems. This means that the Dutch government is investing in prevention and is trying to organize the care as close to the patient as possible. Because in the vicinity of the patient the costs are lower, there is more capacity (volunteer aid) and the accessibility is better. Also for the long term this is the right context to establish a good relationship between provider and the patient.

UCSF Center for Excellence in Primary Care. http://www. ucsf  Source: UCSF Center for Excellence in Primary Care.

To cope with these developments we need a paradigm shift from cure to care. Instead of being reactive and wait until a health problem arise, the public must be stimulated to prevent healthcare problems. This means that the Dutch government is investing in prevention and is trying to organize the care as close to the patient as possible. Because in the vicinity of the patient the costs are lower, there is more capacity (volunteer aid) and the accessibility is better. Also for the long term this is the right context to establish a good relationship between provider and the patient.

Integratie: Verschillende vormen van schaalvergroting Systeem integratie Politieke omgevingsklimaat Organisatie integratie Samenwerking tussen organisaties Professionele integratie Samenwerking tussen professionals Klinische en service integratie Vloeiend proces van zorg & dienstverlening Functionele Integratie Technische ‘enablers’(ICT, Facilitair) Normatieve integratie Sociale ‘enablers’(Cultuur, vertrouwen) We have a discussion…….curios your ideas… Lokaal (micro) Regionaal (meso) Landelijk (macro)

To cope with these developments we need a paradigm shift from cure to care. Instead of being reactive and wait until a health problem arise, the public must be stimulated to prevent healthcare problems. This means that the Dutch government is investing in prevention and is trying to organize the care as close to the patient as possible. Because in the vicinity of the patient the costs are lower, there is more capacity (volunteer aid) and the accessibility is better. Also for the long term this is the right context to establish a good relationship between provider and the patient.

Per capita cost: Risico's verplaatsen

To cope with these developments we need a paradigm shift from cure to care. Instead of being reactive and wait until a health problem arise, the public must be stimulated to prevent healthcare problems. This means that the Dutch government is investing in prevention and is trying to organize the care as close to the patient as possible. Because in the vicinity of the patient the costs are lower, there is more capacity (volunteer aid) and the accessibility is better. Also for the long term this is the right context to establish a good relationship between provider and the patient.

Health Promotion: Gezondheid & Populatie FIGURE 1. Primary care versus outcome indicators (rank 1 is best, rank 12 is worst). *--Rank is based on patient satisfaction, expenditures per person, 14 health indicators, and medications per person.

Werkt dit ergens? Initiatief Land Populatie Triple Aim uitkomsten Blue Cross Alternative Quality Contract 5 jaar 1,35 miljoen verzekerden* Kwaliteit score 25% omhoog (obv 34 kwaliteit/tevredenheidindicatoren) Shared savings t.o.v. trend van 5.8%-9.1% * Torbay/Devon Community Care Group meerjaren totaalbudgetten (Health & Social Act 2012) 281.900 verzekerden 33% daling ziekenhuis bedbezetting 24% daling spoedopnames 75+ Minder ouderen in verpleeghuizen Geen vertraging meer in transmurale zorgoverdracht Resterend budget wordt volledig geïnvesteerd in preventie Krijgt nu nationale navolging Gesundes Kinzigtal Shared savings contract 10 jaar en verlengd 32.000 verzekerden 53% minder sterfgevallen na hartfalen 1,5 jaar langer leven GK deelnemers 23% minder groei ZKH opnamen 40% minder opnames GGZ 10% meer verzekerden ZV AOK ‘Shared saving’ per AOK verzekerde: €150 per verzekerde per jaar (-10%) Bron: VEROZ White paper 2014 *Song et al NEJM 371;18

Ervaringen in Nederland vanaf 2000: invoeren Diabetesmanagement Vanaf 2005: invoering bundles in de ziekenhuizen (DBC/DOT) Vanaf 2007: integrale bekostiging (bundle payment voor uitsluitend de chronische zorg in de eerste lijn) Landelijke invoer voor diabetes: Veel kwalitetsverbetering Veel meer mensen met diabetes in beeld Betere meting van gezondheidstoestand Na 10 jaar: voorzichtig enige indicatie voor kostenreductie Gedeeltelijke invoer voor COPD, VRM, Astma Vanaf 2013: proeftuinen populatiemanagement Nog geen duidelijke resultaten PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

Disease management Community care Hoe hebben we dit nu in Nederland in de laatste decennia gestimuleerd: vanuit de eerste lijn? Ziektespecifiek individuele aanpak zorgstandaarden integrale bekostiging zorggroepen integratie 1e en 2e lijn 1,5e lijns centra Community populatie aanpak zorgprogramma’s GEZ module gezondheidscentra integratie 1e en 0e lijn van ZZ naar GG Disease management Community care PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’ Maatschappelijke rationaliteit Ondernemersrationaliteit

Populatiegerichte zorg: wat zien we nu in Nederland? Proeftuinen Anderhalfdelijnszorg Herpositionering ziekenhuiszorg Integrale geboortezorg

(bedrijfs)economisch Ervaringen: Succesfactoren voor samenwerking tussen domeinen Monitoren resultaten: PDCA populatiegericht doelmatigheid Haarlemmerolie Boven eigen organisatiebelang Steady Kernteam Professioneel belang (bedrijfs)economisch belang Bestuurlijk vertrouwen Organisational integration = most discussed form of integration in the literature It can: improve quality, market share and efficiency in a health care system The extend of integration activity between organizations…… ranging from…. Different organizational governance principles can be distinguished: Market environment Networkmechanisms Hierarchical mechanisms Typology of 'loose' to 'tight' governance agreements is widespread in alliance and network literature… as preseted by Gomess-Caseres PC: is a favorable environment for network-like partnerships because of its relative stability and shared social norms 'loose' to 'tight' governance agreements Professionals overtuigen professionals Langdurige samenwerking

Kenmerken Population Health Management Hele zorg continuum: "intensive care management for individuals at the highest level of risk" and "personal health management... for those at lower levels of predicted health risk.“ Meer dan één chronische aandoening: niet ziektespecifiek oppakken Meer dan één coördinatiepunt in de zorg is Voorspellend modelleren Verbeteren van kwaliteit, gezondheid en financiële uitkomsten (Triple Aim) Verscheidenheid aan individuele, organisationele en culturele interventies Binnen GEDEFINIEERDE populaties (Geografisch afgelijnde regio) PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

Risk Stratification according to Kaiser Permanente PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

Identification of the risks Case finding is a systematic or opportunistic process that identifies individuals (e.g. people with COPD) from a larger population for a specific purpose for example, ‘Flu vaccination. 2. Risk stratification is a systematic process that divides a population into different strata of risk for a specified outcome, e.g. unscheduled admission to hospital (it can be used for commissioning). 3. Case finding for risk stratification which is a systematic process to identify sectors of the population that may benefit from additional clinical intervention, as directed by a lead clinician such as the patient’s GP. PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

Two different approaches 2. Risk Stratification: Predictive Modeling Utilizes routinely collected data to gather up cohorts of patients meeting specific pre-determined criteria and establish a statistical relationship between the variables and the occurrence of an adverse event in a defined future period. Prediction of: Unplanned hospitalization ED visit High cost High pharmacy use Specific tools have been developed (i.a. John Hopkins ACG, HCC) PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

Diseasemanagement: COPD in Nijkerk Een voorbeeld van een case finding aanpak: PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’ Diseasemanagement: COPD in Nijkerk

We vinden de tikkende ‘tijdbommen’ Optimaliseren van de zorglogistiek Optimaliseren van de zorglogistiek Zuiverder diagnostiek We ‘resetten’ medicatie

An example of a risk function: Risk estimation of frail elderly PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

Panelmanagement of frail elderly: OmU project Frailty screening software: Identification predictors Sex / age Polypharmacy Consultation gap Frailty Index Geriatric events Psychosocial events Multimorbidity During 5 year follow-up: Identification outcome measures Nursing home admission Mortality PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

Result: model to estimate risks Algorithm 5-year Predicted risks Observed risks Model 3 Low risico Intermediate risico High risico Total   4.4% 10.1% 35.6% 16.7% 4.0% (179/4473) 8.7% (389/4474) 32.3% (1445/4473) 15.0% (2013/13420) Model for frail elderly predicts admission in nursing home and mortality excellent! PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’ Tip: make use of already proven experiences!

How Do We Transform Care for Our Members with Much Less $$$? Population Health "Triple Aim" Experience of Care Cost per Capita WHAT DOES THE DATA TELL US…

REbecca Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations Cynthia Boyd, Bruce Leff, Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Martin CHCS DECEMBER 2010

Triple Aim Approach to High Cost/High Risk Patients 34

Claims Data for 12 Month Period CareOregon Medicaid Adults only (19yrs+) living in TriCounty Area Claims Data for 12 Month Period 13% of members account for 52% of paid cost

Begrijpen oorzaken 15 Case Review Method “Act for the Individual to LEARN for the population” Werkelijke oorzaken Multidisciplinaire eerstelijnsteam aanpak niet voldoende Nieuwe gezondheidscoach (resilience worker) Rebecca

What Did CareOregon Learn About Root Causes? We got to know William and David and other individuals like them, and we discovered, not unlike the previous data suggests: Most clients have had an overwhelmingly negative experience with the healthcare system; most clients primarily identify as ill and as a patient Homelessness and food insecurity; chaotic lives burdened with cumbersome eligibility requirements for social programs Prevalence of Substance Abuse and mental health conditions, mild to moderate cognitive deficits Poor health literacy Lack of timely access to psychiatric assessment and mental health respite services Care coordination needs extensive (particularly between sites of care) Many cant afford or do not have access to items or services critical to optimal health and self management ( ie transportation, healthy food, medications, place to exercise, etc)

The REAL Common Denominator: Adverse Childhood Events & Trauma ACE Score = 1 point each for positive responses to 10 questions inquiring about exposure to: Physical abuse Emotional abuse Sexual abuse Physical neglect Emotional neglect Divorce/separation Domestic violence in the home Parent that used drugs or alcohol Parent that was incarcerated Parent that was mentally ill How many of you are familiar with the Adverse Childhood Experiences Study published in the 90’s This translates into distrust of people in authority positions, and certain behaviors that appear very disruptive and destructive to us but that stem from having to adapt and protect oneself when living in unsafe environments

A new workforce approach that enhances primary care teams In Oregon, we have highly functional safety net primary care teams and good to great access. Since 2006, we have worked to implement key principles of the SCF medical home model: Team based care (with many of the roles at SCC, but higher panel sizes) Proactive panel management Barrier free access Patient driven Behavioral health integration But for some very high cost patients, even this isn’t enough to meet their needs.

Health Resilience Interventions Motivational Interviewing to resolve ambivalence about health-related behavior change Client advocacy within and among multiple systems Role modeling advocacy and relational skills; trauma-recovery Assistance in navigating health care system Care coordination Health literacy education Self management skill development Assistance with complex problem solving related to living in poverty with multiple health issues Providing opportunities to identify as something other than a “patient” Providing opportunities to experience success and feel confident Deep listening, acknowledgment and respect for each individual

Health Resilience Program 222 Clients Engaged AT LEAST 1x On or Before June 30th, 2013 Median PMPY Rate Pre: 2.0 Post: 1.3

Health Resilience Program 222 Clients Engaged AT LEAST 1x On or Before June 30th, 2013 Median PMPY Rate Pre: 9.3 Post: 6.2

Wat heb je minimaal nodig om in de regio met het netwerk populatiegericht aan de slag te gaan? In de pilootprojecten is de noodzaak voor een regionale governance over de uitvoering van de activiteiten voor de doelgroep nodig. In het blauwe vlak : de TA infrastructure wordt gesproken over een ‘Government Structure’; deze zal in vrijwel alle pilootprojecten bestaan uit een netwerk van organisaties. De ‘’governance’ ofwel de besturing van een netwerk is en blijft een lastig aspect. Binnen deze structuur wordt besluitvorming en monitoring gerealiseerd. Aangezien het in de toekomst ook over de verdeling van (financiële) middelen gaat is het van belang dat bij de projectaanvraag dit goed moet zijn ingericht. In de literatuur worden drie verschillende netwerkstructuren met de bijbehorende karakteristieken en effectiviteit besproken (artikel Provan&Kenis). Deze vormen zijn:

Noodzaak regionale governance structuur Stap 1: Integrator De belemmeringen zijn niet technisch, maar worden veroorzaakt door belangentegenstellingen (politiek!) Noodzaak voor een integrator: een entiteit gelegitimeerd in de region die verantwoordelijkheid neemt voor de drieledige doelstelling (dus inhoudelijke en financiële verantwoordelijkheid). In de pilootprojecten taken van de integrator: Integratie van patient en zijn/haar omgeving in het zorgproces Geïntegreerd multidisciplinair werken op alle niveau’s Andere kijk op zorg- en hulpsysteem: kwaliteit, financiering, risicostratificatie e.d. Noodzaak regionale governance structuur PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

De drie vormen spreken voor zich. In het eerste geval is er sprake van shared governance; netwerkleden participeren in gelijkwaardigheid in de organisatie: gevaar inefficiëntie, iedereen moet meedoen. En particpeert men als vertegenwoordiger van het eigen netwerk of organisatie (en zitten er dus nog vele andere netwerken achter??) of participeert de organisatie? In het tweede geval is er sprake van één dominante organisatie, veelal indien er sprake is van een verticale relatie. In de huidige constellatie wordt veelal het ziekenhuis een dergelijke rol toegedicht en dat vinden de andere partners veelal onwenselijk aangezien dan sprake is ‘doordrukken in kader van eigen belang’ In het derde geval is sprake van een andere netwerkentiteit. Dit is meestal een organisatie die coördinerende en administratieve taken voor de rekening neemt. Indien meer en meer besluitvorming hier naar verschuift krijgt de NAO meer en meer het karakter van een lead organisatie. Provan & Kenis

Structuur van de netwerk governance ? (1) Opvallend in deze gebieden is dat in alle gevallen een vergelijkbare structuur ontstaat, namelijk de derde: een structuur met een netwerk-administratieve organisatie. Deze netwerk administratieve organisatie is de organisatie die de contracten met de betalers sluit en

Structuur van de netwerk governance ? (2) Provan & Kenis

Karakeristiek Vertrouwen Groeiend? Aantal Netwerkleden Veel Toepassing van de karakteristieken op West Vlaanderen Karakeristiek Vertrouwen Groeiend? Aantal Netwerkleden Veel Doelconsensus Hoog Netwerkcompetenties Laag PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’

Structuur van de netwerk governance in pilootgebieden? Piloot project contract RIZIV Netwerk Administratieve Organisatie Voor de pilootporjecten lijkt het dus zeer verstandig om een structuur te kiezen met een Netwerk administratieve Organisaties die uiteindelijk kan doorgroeien naar de accountable care organisatie voor diverse populaties.

Triple Aim congres | 11 juni 2015

Cultuur van de netwerk governance? Besluitvorming: collectief vs corporate Professionalisme versus managerial Eigen belang versus collectief belang Voor de pilootporjecten lijkt het dus zeer verstandig om een structuur te kiezen met een Netwerk administratieve Organisaties die uiteindelijk kan doorgroeien naar de accountable care organisatie voor diverse populaties.

Uw Keuze: van reactief naar proactief met een regionale governance? Start met zichtbaar maken van: Populatiedoelstelling en risicostraticatie Regionale Governance: Creëer een cultuur van vertrouwen Integrator Netwerk administratieve organisatie PC = primary care definition of the Alma Ata declaration of 1978 focusses on: - Health promotion and prevention - Contains: Intersecoriaal collaboration appraoch Despite the complex and broad societal description of primary care. Starfield gave a precise definition of the functions of primary care. Integration and IOR = no uniform definition.  ‘Hampers a systematic understanding’