Integrated service delivery in Portuguese primary health care

Transcription

1 23rd European Social Services Conference Lisbon 2015, 6-8 July Workshop session: Connecting primary care and prevention for integrated service delivery Integrated service delivery in Portuguese primary health care António Pereira, André Biscaia, Sílvia Machaqueiro Research project: Commissioning in Primary Health Care in Portugal: Research and Practice A Joint Approach ( Contratualização em Cuidados de Saúde Primários: Investigação e Prática uma abordagem conjunta, ref. INSA/ EXT)

2 Outline Why do we need integrated care? What do we mean by integrated care? Integrated service delivery How to achieve health care integration? Integration of care in Portugal Measuring Integrated Care 2

3 Why do we need integrated care? One of the responses to current health system challenges (ageing societies, burden of chronic disease, multimorbidity ) Care patterns with multiple providers a typical patient sees a median of two primary care physicians and five specialists each year, in addition to accessing diagnostics, pharmacy, and other services (Strandberg-Larsen, 2011) Achieving greater efficiency and value from health delivery systems by: Addressing fragmentation in patient services Providing better coordinated and more continuous care 3

4 What do we mean by integrated care? Organising principle for delivering health care aiming at: Improvement of patient experience Achieving greater value from health delivery systems Addressing fragmentation in patient services Enabling better coordinated and more continuous care Integration involves connecting the health care system (acute, community and primary medical) with other service systems (such as long-term care, education or housing services) in order to improve outcomes (clinical, satisfaction, efficiency). Concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Means to improve the services in relation to access, quality, user satisfaction and efficiency. The Nuffield Trust, 2011; Leutz, 1999; Gröne & Garcia-Barbero,

5 What do we mean by integrated care? Planning Financing Different health and social care providers coming together Policy-makers Leaders Information systems Information sharing Patient needs at the centre The King s Fund,

6 What do we mean by integrated care? Strandberg-Larsen,

7 Integrated Service Delivery The management and delivery of health services so that patients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system. Poor integration of primary, secondary and tertiary care lead to inefficiency and lack of quality, creating unnecessary difficulties for health care users. OMS 2008; Lopes et al.,

8 How to achieve health care integration? Development of disease management programmes Sharing of activity plans and budget Sharing of administrative procedures Integration of clinical data Implementation of communication systems Case management Creation of cross-disciplinary teams Training programmes involving different medical professionals Development of patient referral systems Lopes et al.,

9 Integration of care in Portugal 9

10 Horizontal integration Vertical integration Santana,

11 Santana,

12 Still some barriers to integration of care: Different entry points into the health system Difficult information flow between institutions and professionals Separation between health and social care Little public provision of community care services in Portugal (including long-term care) 12

13 However, some integration mechanisms are already in place: Clinical guidelines Strengthening of the evaluation and quality culture Development of training and development plans between clinical leaderships in ACES and hospitals emphasis on interfaces among levels of care Implementation of RNCCI (2006) under two different Ministries + links with acute care hospitals and health centres Combines teams providing long-term care, social support and palliative activity within community services, covering hospitals, local and district social security services, the Solidarity Network and municipalities. Creation of Family Health Units (USF) primary care Pisco,

14 Hospitals Board Executive Director Executive Council Clinical Council Comunity Council Ministry of Health ARS Regional Health Administrations (x 5) UAG ACES - Health centre groups x 74 (55) Functional Units URAP USP x 74 UCC x 232 UCSP x 459 USF x 421 Author: André Biscaia PHC Reform 2005 Implementation of USF/FHU (Family Health Units) Restructuring of health centres Health Centre Groups Population: to Management structure, shared resources and tools USF self-organised, multiprofessional care-providing teams UCSP Equivalent to USF but under the traditional model URAP Shared Resources (psychologists; nutritionists; social workers) USP Public Health Services UCC Community Care Unity (run by nurses) UAG - Management support unit 14

15 Integration of care in Portugal Integrated care processes Joint action plans Through cooperation between ACES and hospitals clinical boards for some types of conditions 15

16 EXAMPLE OF AN INTEGRATED CARE PROCESS FOR PATIENTS WITH VASCULAR RISK DGS,

17 Integration of care in Portugal Some tools and mechanisms Electronic referral system PHC hospital (Consulta a tempo e horas CTH) Development of referral mechanism from a whole-referralcycle perspective: starting point assessment response arrival assessment and conclusion of the process in PHC. Health Data Platform Access to essential available information: Clinical assessment Active problems Exam results (including imaging, therapies, risks and specific alerts) 17

18 Integration of care in Portugal Some tools and mechanisms Portal BI USF Accountability Sharing procedures 18

19 Integration of care in Portugal Some tools and mechanisms Portal BI USF Accountability Sharing procedures 19

20 Patient referral Attempts at integrating care provision Organisational models Secondary care (hospital) LOCAL HEALTH UNIT (ULS) Secondary care (hospital) Tertiary care Public Health Unit ACES Family Health Unit Manageme nt Support Unit Public Health Unit ACES Family Health Unit Manageme nt Support Unit Personalise d care Unit Community Care Unit Personalise d care Unit Community Care Unit Source: Machaqueiro & Lapão,

21 However, evidence shows ULSs haven t met integration and performance expectations Source: Jornal Público 21

22 However, evidence shows ULSs haven t met integration and performance expectations 22 Source: Jornal Público Source: Jornal de Negócios

23 However, evidence shows ULSs haven t met integration and performance expectations ERS, Source: Jornal Público Source: Jornal de Negócios

24 Positive steps taken towards integrated care in Portugal Integration of clinical data Implementation of communication systems Case management Creation of cross-disciplinary teams Training programmes involving different medical professionals Development of patient referral systems OECD,

25 Challenges to integrated care OECD,

26 Measuring integrated care PIRU,

27 Measuring integrated care Singer,

28 23rd European Social Services Conference Lisbon 2015, 6-8 July Workshop session: Connecting primary care and prevention for integrated service delivery Thank you António Pereira, André Biscaia, Sílvia Machaqueiro Research project: Commissioning in Primary Health Care in Portugal: Research and Practice A Joint Approach ( Contratualização em Cuidados de Saúde Primários: Investigação e Prática uma abordagem conjunta, ref. INSA/ EXT)

29 References DGS (2014). Informação 009/2014: Processo Assistencial Integrado do Risco Cardiovascular no Adulto. Lisboa: DGS. Gröne O, Garcia-Barbero M (2001). Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. International Journal of Integrated Care; Jun 1; 1. Jornal de Negócios. Unidades Locais de Saúde "exibem uma menor dotação" de profissionais. tml. 13/02/2015. Leutz WN (1999). Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Quarterly; 77(1): Lopes [et al] (2014). Relatório do Grupo de Trabalho criado para a definição de proposta de metodologia de integração dos níveis de cuidados de saúde para Portugal Continental. Trabalho realizado no âmbito do Despacho nº 9567/2013, de Sua Excelência o Secretário de Estado Adjunto do Ministro da Saúde, de 10 de Julho, publicado no Diário da República, 2ª série, nº 139, de 22 de Julho de Machaqueiro S, Lapão LV (2013). What s a Manager s Job in Primary Healthcare units? An attempt to understand management challenges in the context of the complexity of a health reform process. Oral communication at the 20 th World Conference, Family medicine: care for generations Prague, June OECD (2015). OECD Reviews of Health Care Quality: Portugal Raising Standards. Paris: OECD Publishing. PIRU (2014). Integrated Care and Support Pioneers: Indicators for measuring the quality of integrated care. Pisco L (2008). Integrated care in Portugal. Revista de Innovación Sanitaria y Atención Integrada: Vol. 1: Iss. 1, Article 6. Público. Unidades Locais de Saúde não estão a evitar internamentos desnecessários. 13/02/2015. Santana R, Costa C (2008). A integração vertical de cuidados de saúde: aspectos conceptuais e organizacionais. Revista Portuguesa de Saúde Pública, 7: Santana R, Szczygiel N, Redondo P (2014). Integration of care systems in Portugal: anatomy of recent reforms. Int J Integr Care 2014; Jul Sep;. Shaw S, Rosen R, Rumbold B (2011). What is integrated care? An overview of integrated care in the NHS. London: The Nuffield Trust. Singer SJ, Burgers J, Friedberg M, Rosenthal MB, Leape L, Schneider E. Defining and measuring integrated patient care: promoting the nest frontier in health care delivery. Medical Care Research and Review 2011;68: Strandberg-Larsen M (2011). Measuring Integrated Care: An International Comparative Study. Danish Medical Bulletin; 58(2):B4245. The King s Fund (2013). Joined-up care: Sam's story. World Health Organization. Integrated health services - what and why? Technical Brief No.1,