Integrated or not integrated? Which future for Primary Care Groups (PCGs)?

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1 Integrated or not integrated? Which future for Primary Care Groups (PCGs)? Emanuela Foglia, Emanuele Porazzi, Umberto Restelli, Francesca Scolari, Daniela Malnis, Giovanni Beghi, Antonino Mazzone, Carla Dotti Bern, European Health Management Association - EHMA 2012

2 Agenda Primary Care: Evidence from international and national literature Research Problems Study s Objective The Italian Background Lombardy Region LHA Milano 1 and HA Ospedale Civile di Legnano : a case of Hospital - Primary Care integration Methods Results Conclusions References

3 Primary Care: Evidence from International and National Literature PRIMARY CARE Ensuring the continuity of patient care (Bodenheimer et al., 2002; Fioravanti et al., 2007, Longo, 2007; Fattore et al. 2009) Increasing the appropriateness, effectiveness and efficiency of care (Berg et al., 2006; Heath et al., 2009; Solberg et al., 2009) Reducing socioeconomic and geographic disparities across the population (Ferrer et al., 2005) ASSOCIATIVE MEDICINE Evidence of effectiveness of associative models of primary care in chronic diseases (Bodenheimer et al., 2002; Olivarius, 2001; Soulberg et al., 2009; Mehrotra et al., 2009; Mascia et al., 2008) Better performances in the case of GPs networks/groups, than for individual practitioners (Longo 2007; Mannino et al., 2009; Fantini et al., 2010) Discontinuity of care at the interface between inpatient and outpatient management can lead to increased morbidity and mortality (Tandjung et al., 2011)

4 Research Questions THE IDENTIFIED PROBLEMS - BACKGROUND Low diffusion of PC Associative Models in Italy and Lombardy Region (IRER, 2010; Damiani, 2007; AGENAS, 2009; Mannino, 2009) Lack of territorial performance indicators for evaluating performance of different organizational models (McElduff, 2004; Mascia, 2008; Eath, 2009; Fattore, 2009) RESEARCH QUESTIONS 1. How to assess the efficiency of PCGs? 2. How to evaluate performance in terms of effectiveness?

5 The Study s objective The Study investigated the impact of PCGs introduction on the overall performance of District 4 (and LHA Milano1) in terms of: 1. rate of hospitalization efficiency 2. mortality rate effectiveness for patients suffering from specific chronic diseases

6 Primary Care: The Italian Background GP gatekeeper Hospital (Secondary/Tertiary Care) ITALIAN TRENDS Aging of population (1 st in Europe with people > 65 years European Commission, 2011) Complexity of Health Care demand: increasing of chronic diseases and fragile patients Lack of economic resources LHA GP or PCGs (Primary Care) Responsibile for providing comprehensive healthcare (health prevention, primary and community care)

7 Primary Care: The Italian Background In the last 20 years Healthcare Reforms in Italy and all Western Europe have reshaped Primary Care and the role of GPs: Legislative Decree 502/1992: first reference to Associative Medicine Legislative Decree 229/1999: District as citizens reference point for the access to Primary Primary Care (through Local Health Authority) Italian National Healthcare Plan : new strategic guidelines for the empowerment of Primary Care as the introduction of new financial inventive schemes, ICT support, the development of a first network for integrating hospital and territorial assistance (Primary Care Unit UTAP) State Regions National Agreement (2004 and 2006): innovative models of Associative Medicine in Primary Care (from the experience of PCGs in the UK) in order to ensure the continuity of patients care The GPs National Collective Agreement of 2009: empowerment of GPs role in order to achieve greater functional integration between the professionals. Implementation of economic incentives by LHAs for group practices, encouraging GPs to participate in collaborative arrangements

8 Primary Care: The Italian Background COMPLEXITY Low Medium High Characteristics: GPs Simple Association GPs Network GPs Group Professional Associates Location Sharing of therapeutic, diagnostic and clinical guidelines or pathway Min. 3 Max.10 Not bound to a single location Min. 3 Max. 10 (not compulsory) Not bound to a single location, but possibility to rotate to different locations Min. 3 Max. 8 Single location divided into several medical studios Yes Yes Yes Common use of ICT Support No No Yes (computer links and files sharing) Common use of administrative personnel No Yes (specific Agreement with Regions and in the face of economic incentive) Yes (specific Agreement with Regions and in the face of economic incentive) Source: Art. 40 NCA 2000

9 Lombardy Region DIFFUSION OF ASSOCIATIVE MODELS FOR GPs IN LOMBARDY REGION Despite health care reform Legislation, which has focused national and regional attention on the central role GPs and team based care, institutional research has shown poor implementation of Primary Care innovative organizational models Associative Models Diffusion in Lombardy Region (2010) 24% 29% 15% 32% Single GP GPs in Simple Association GPs Network GPs Groups Source: IRER 2010

10 Local Health Authority Milano 1 GPs ASSOCIATIVE MODELS DISTRIBUTIONS PER DISTRICT (LHA MILANO 1) Single GPs Simple Association Netowork Group District GPs No. % No. % No. % No. % District % 19 16% 57 47% 20 17% District % 3 3% 31 28% 49 45% District % 3 4% 33 43% 15 20% District % % 60 50% District % 4 9% 23 50% 7 15% District % % 30 38% District % 3 6% 13 27% 7 15% TOT GPs in LHA Milano % 32 5% % % TOT Pop LHA Milano 1, Strategic Planning Document, 2012

11 A Case of Hospital - Primary Care Integration The project of LHA Milano 1 and Hospital Autority Ospedale Civile di Legnano GPs ORGANIZATIONAL MODEL Mission: provide users with the delivery of primary care, in collaboration and constant comparison with Specialists, in order to ensure continuity of care and promote greater appropriateness Hours: Extended hours (late afternoon or Saturday morning) How often? Once every week Specialists go to PCG to carry out the scheduled visit/consultation Characteristics of patients selected to be examined by Specialists: fragile patients, with comorbidity, not yet hospitalized, who need multidimensional approach to care Territory characteristics: medium-large Municipalities close to each other, high-medium income and education, the majority of population commute to bigger cities

12 A Case of Hospital - Primary Care Integration Organisational model of reference GPs Hospital Specialist (Diabetologist, Rheumatologist, Pulmonologist, Cardiologist) The GPs select patients Agreement PC Groups LHA Milano 1 Health District 4 - Legnano

13 DATA SOURCES Methods LHA Milano 1 Dataset (Department of Primary Care): Data used in the study were provided by the LHA Milano 1 administrative dataset Hospital Authority Ospedale Civile of Legnano: Discharge records ISTAT (Italian National Institute of Statistics): demographic and performance (mortality rate) data PERIOD OF STUDY (3 years) POPULATION 3 PCGs: 30,240 patients LHA Milano 1: 940,767 residents Health District 4: 186,188 residents

14 Results Hospitalization Rate (*1,000) in PCGs: a comparison between the PCGs, District 4 and LHA Milano 1 170,00 PCG A+B+C 165,00 DISTRICT 4 (no A+B+C) 160,00 155,00 LHA MILANO 1 (no A+B+C and District 4) 150,00 p value < ,00 p value < , Source: CREMS reprocessing of the study data

15 Results Mortality Rate (*1,000) in PCGs compared with LHA Milano 1 10,00 PCGs A+B+C 9,50 DISTRICT 4 (no A+B+C) 9,00 8,50 p value < 0.01 LHA MI 1 (no District 4 and A+B+C) ITALY MORTALITY RATE 8,00 7,50 7,00 p value < ,50 6, Source: CREMS reprocessing of the study data

16 Conclusions The study demonstrates the importance to focus on new organisational models, with pathways that link General Practitioners and hospitals Specialists, in order to ensure continuity and better quality of care Although the per thousand hospitalization rate reveals a better performance for the District in terms of efficiency, the situation changes when considering the results in terms of effectiveness After 3 years of implementation, GPs have better performance in terms of mortality rate, followed by LHA and District 4 for major chronic diseases (per thousand mortality rate as the hard endpoint to study the imporvement) Can the model be extended and used in different contexts?

17 Thank you for your attention

18 References Agenas, Stato di attuazione dei modelli innovativi di assistenza primaria nelle Regioni italiane, Progetto di ricerca corrente finanziato dal Ministero del Lavoro, della Salute e delle Politiche Sociali negli anni , Maggio 2009 Berg M., De Brantes F., Schellekens W., The right incentives for high-quality, affordable care: a new form of regulated competition, International Journal for Quality in Health Care, 18 (4), 2006, pp Bodenheimer T., Wagner E.H., Grumbach K., Improving Primary Care for Patients with Chronic Illness, JAMA, 288(14), 2002, pp Damiani G., Venditti A., Palumbo D., Rizzato E., Guzzanti E., Assistenza Primaria: significato e prospettive di sviluppo organizzativo, Organizzazione Sanitaria, 2, 2007, pp Fantini M.P., Carretta S., Mimmi S., Beletti M., Rucci P., Cavazza G., Di Martini M., Longo F., L impatto delle caratteristiche e dell organizzazione dei MMG sulla qualità assistenziale delle malattie croniche, Mecosan, 2010, 73, pp Ferrer R.L., Hmabidge S.J., Maly R.C., The essential role of generalists in health care systems, Annals of Internal Internal Medicine, 2005; 142(8): Fioravanti L., Spandonaro F., Continuità assistenziale dal principio alla realizzazione: cosa insegna il disease management, Politiche sanitarie, 2007, 8(1), 28-33

19 References Heath I., Rubistein A., Stange K.C., Van Driel M.L., Quality in primary health care: a multidimensional approach to complexity, BMJ, 338, 2009, pp IRER Istituto Regionale di Ricerca di Regione Lombardia, Definizione di nuovi modelli di gestione dei Medici di Medicina Generale (MMG), differenziati in base alle specificità territoriali e coerenti con i bisogni dei cittadini e con il modello gestionale basato sul consulto formativo, Milano, Marzo 2010 Longo F., Implementing managerial innovation in Primary Care: Can we rank change drivers in complex adoptive organizations?, Health Care Management Review, n. 3, pp. 1-13, 2007 Mannino S., Villa M., Lucchi S., Brunelli G., Locatelli G.W., Zenoni S., Longo F., Variazioni delle performance dei MMG in relazione dalle forme associative, Mecosan, 70, 2009, pp Olivarius N.F., Beck-Nielsen H., Andreasen A.H., Hørder M., Pedersen P.A., Randomised Controlled Trial of Structured Personal Care of Type 2 Diabetes Mellitus, British Medical Journal, 323(7391), 2001, pp Solberg L.I., Asches S.E., Shortell S.M., Gillies R.R., Taylor N., Pawlson L.G., Scholles S.H., Young M.R., Is Integration in Large Medical Groups Associated With Quality?, American Journal of Managed Care, 15(6), 2009, pp Vendramini E., Lega F., Budgeting and performance management in the Italian National Healt System: assessment and constructive criticism, Journal of Health Organization and Management, 2008, 22 ()1), pp

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