Introducing coordinated care (2): evaluation of design features and implementation processes implications for a preferred health system reform model

Defining Pooled' Place-Based' Budgets for Health and Social Care: A Scoping Review

Introduction

Current descriptions of pooled budgets in the literature pose challenges to good quality evaluation of their contribution to integrated care. Addressing this gap is increasingly important given the shift from early models of integrated care targeting segments of the population, to more recent approaches that aim to target 'places', broader geographically defined populations. This review draws on the current international evidence to describe practical examples of pooled health and social care budgets, highlighting specific place-based approaches.

Methods

We initially conducted a scoping review, a systematic database search ('Medline', 'Embase', 'Econ Lit' and 'Google Scholar') complemented by further snowballing for academic and 'grey literature' publications (1995 - 2020). Results were analysed thematically according to budget characteristics and macro-environment, with additional specific case studies.

Results

Thirty-six primary studies were included, describing ten broad models of pooled budgets across seven countries. Most budgets targeted specific sub-populations rather than an entire geographically defined population. Specific budget structures varied and were generally under-described. The closest place-based models were for small populations and implemented in a national health system, or insurance-based with natural geographical boundaries.

Conclusion

Despite their increasing relevance in the current political debate, pooled place-based budgets are still at an early stage of implementation and research. Adequate description is required for future meta-analysis of effectiveness on outcomes.

Exploring enablers of modularity in healthcare service delivery

Purpose

This paper explores the enablers of modular healthcare services.

Design/methodology/approach

A survey-based approach was adopted with specialised hospitals as the unit of analysis. A structural model was developed based on a literature review and assessed using a cross-sectional research design. A 23-indicator questionnaire was circulated among service providers in the healthcare system across India, and 286 valid responses were received. The data were analysed using partial least squares-structural equation modeling (PLS-SEM).

Findings

The results reveal that professional competence, technological versatility, clear division of tasks, channelised flow of information and professional autonomy act as enablers that may drive modular service delivery.

Research limitations/implications

By examining service providers' perspectives, this paper highlights the influence of the identified enablers on modular service delivery in healthcare organisations.

Practical implications

For practitioners, the study provides suggestions for designing patient-centric healthcare services via modular healthcare delivery. The identified structural relationships can facilitate immediate corrective actions and the formulation of future policies. The findings will help practitioners foresee opportunities for patient participation in value co-creation, meet patients' varying needs, decompose service offerings, mix and match components develop sets of rules as interfaces between service modules and design service packages on an ongoing basis.

Social implications

This study underscores the emergence of patient-centric care and may aid the design of processes that deliver health to the patient as a person.

Originality/value

This paper identifies and empirically validates relationships between healthcare service delivery processes and modular service delivery.

The effect of the integration of health services on health care usage among patients with type 2 diabetes in North Karelia, Finland

BACKGROUND

The need to improve the care of people with complex care requirements has been driving the reforms integrating care processes. This study examines the effect of the integration of health services on health care usage and the processes and outcomes of care among type 2 diabetes patients.

METHODS

Data include all type 2 diabetes patients who lived in North Karelia, Finland, between 2014 and 2018. Health care contacts and glycated haemoglobin (HbA1c) measurements were obtained from the electronic health records. Logistic, Poisson and linear models with generalised estimating equations and the Friedman test were used to study the differences between years.

RESULTS

The health care usage was highest in 2017, the first year of a new organisation, and smallest in the following year. Before the new organisation, the health care usage was lowest in 2014, being slightly higher compared with 2018. Between the last two years, the mean number of contacts per person declined from 3.25 to 2.88 (-0.37, p < 0.001). The decreasing pattern seen in total health care usage was most obvious among contacts with primary health care nurses. The number of contacts increased only among specialised care nurses between the last two years. The number of HbA1c measurements was also in its lowest in 2018 but in its highest in 2015. Between the years 2014 and 2018, the difference in the mean number of contacts was - 0.05 (p = 0.011) for those not measured, -0.02 (p = 0.225) for those measured and within the target level of HbA1c, and 0.12 (p = 0.001) for those measured and not at the target level of HbA1c.

CONCLUSIONS

Health care integration first increased the health care usage but then brought it to a slightly lower level than before. The changes were most obvious in primary health care nurses' appointments, and no decline was observed in secondary-level care. Even though the numbers of HbA1c measurements and the proportion measured declined, measurements increased among those with poor glycaemic control. The observed changes might reflect the better targeting and more concordant services in different service units.

Capitated Telehealth Coaching Hospital Readmission Service in Australia: Pragmatic Controlled Evaluation

Background

MonashWatch is a telehealth public hospital outreach pilot service as a component of the Government of Victoria’s statewide redesign initiative called HealthLinks: Chronic Care. Rather than only paying for hospitalizations, projected funding is released earlier to hospitals to allow them to reduce hospitalization costs. MonashWatch introduced a web-based app, Patient Journey Record System, to assess the risk of the journeys of a cohort of patients identified as frequent admitters. Telecare guides call patients using the Patient Journey Record System to flag potential deterioration. Health coaches (nursing and allied health staff) triage risk and adapt care for individuals.

Objective

The aim was a pragmatic controlled evaluation of the impact of MonashWatch on the primary outcome of bed days for acute nonsurgical admissions in the intention-to-treat group versus the usual care group. The secondary outcome was hospital admission rates. The net promoter score was used to gauge satisfaction.

Methods

Patients were recruited into an intention-to-treat group, which included active telehealth and declined/lost/died groups, versus a systematically sampled (4:1) usual care group. A rolling sample of 250-300 active telehealth patients was maintained from December 23, 2016 to June 23, 2019. The outcome—mean bed days in intervention versus control—was adjusted using analysis of covariance for age, gender, admission type, and effective days active in MonashWatch. Time-series analysis tested for trends in change patterns.

Results

MonashWatch recruited 1373 suitable patients who were allocated into the groups: usual care (n=293) and intention-to-treat (n=1080; active telehealth: 471/1080, 43.6%; declined: 485, 44.9%; lost to follow-up: 178 /1080, 10.7%; died: 8/1080, 0.7%). Admission frequency of intention-to-treat compared to that of the usual care group did not significantly improve (P=.05), with a small number of very frequent admitters in the intention-to-treat group. Age, MonashWatch effective days active, and treatment group independently predicted bed days. The analysis of covariance demonstrated a reduction in bed days of 1.14 (P<.001) in the intention-to-treat group compared with that in the usual care group, with 1236 bed days estimated savings. Both groups demonstrated regression-to-the-mean. The downward trend in improved bed days was significantly greater (P<.001) in the intention-to-treat group (Sen slope –406) than in the usual care group (Sen slope –104). The net promoter score was 95% in the active telehealth group compared with typical hospital scores of 77%.

Conclusions

Clinically and statistically meaningful reductions in acute hospital bed days in the intention-to-treat group when compared to that of the usual care group were demonstrated (P<.001), although admission frequency was unchanged with more short stay admissions in the intention-to-treat group. Nonrandomized control selection was a limitation. Nonetheless, MonashWatch was successful in the context of the HealthLinks: Chronic Care capitation initiative and is expanding.

Financing intersectoral action for health: a systematic review of co-financing models

BACKGROUND

Addressing the social and other non-biological determinants of health largely depends on policies and programmes implemented outside the health sector. While there is growing evidence on the effectiveness of interventions that tackle these upstream determinants, the health sector does not typically prioritise them. From a health perspective, they may not be cost-effective because their non-health outcomes tend to be ignored. Non-health sectors may, in turn, undervalue interventions with important co-benefits for population health, given their focus on their own sectoral objectives. The societal value of win-win interventions with impacts on multiple development goals may, therefore, be under-valued and under-resourced, as a result of siloed resource allocation mechanisms. Pooling budgets across sectors could ensure the total multi-sectoral value of these interventions is captured, and sectors' shared goals are achieved more efficiently. Under such a co-financing approach, the cost of interventions with multi-sectoral outcomes would be shared by benefiting sectors, stimulating mutually beneficial cross-sectoral investments. Leveraging funding in other sectors could off-set flat-lining global development assistance for health and optimise public spending. Although there have been experiments with such cross-sectoral co-financing in several settings, there has been limited analysis to examine these models, their performance and their institutional feasibility.

AIM

This study aimed to identify and characterise cross-sectoral co-financing models, their operational modalities, effectiveness, and institutional enablers and barriers.

METHODS

We conducted a systematic review of peer-reviewed and grey literature, following PRISMA guidelines. Studies were included if data was provided on interventions funded across two or more sectors, or multiple budgets. Extracted data were categorised and qualitatively coded.

RESULTS

Of 2751 publications screened, 81 cases of co-financing were identified. Most were from high-income countries (93%), but six innovative models were found in Uganda, Brazil, El Salvador, Mozambique, Zambia, and Kenya that also included non-public and international payers. The highest number of cases involved the health (93%), social care (64%) and education (22%) sectors. Co-financing models were most often implemented with the intention of integrating services across sectors for defined target populations, although models were also found aimed at health promotion activities outside the health sector and cross-sectoral financial rewards. Interventions were either implemented and governed by a single sector or delivered in an integrated manner with cross-sectoral accountability. Resource constraints and political relevance emerged as key enablers of co-financing, while lack of clarity around the roles of different sectoral players and the objectives of the pooling were found to be barriers to success. Although rigorous impact or economic evaluations were scarce, positive process measures were frequently reported with some evidence suggesting co-financing contributed to improved outcomes.

CONCLUSION

Co-financing remains in an exploratory phase, with diverse models having been implemented across sectors and settings. By incentivising intersectoral action on structural inequities and barriers to health interventions, such a novel financing mechanism could contribute to more effective engagement of non-health sectors; to efficiency gains in the financing of universal health coverage; and to simultaneously achieving health and other well-being related sustainable development goals.

Developing a Care Coordination Model Using a Hybrid DEMATEL and PLS-SEM Approach

The aim of this article is to develop and assess a model for care coordination (CC). A novel hybrid approach of Decision-Making Trial and Evaluation Laboratory (DEMATEL) and partial least square structural equation modelling (PLS-SEM) has been used to assess the CC model. The study has been conducted in four phases: (a) literature review, (b) Delphi session, (c) development of CC model through DEMATEL and (d) validation of the model through PLS-SEM. The study involves perspectives of service providers as well as service receivers, for which data were collected from hospitals across India. The literature review and Delphi session helped in finalising the seven measures of CC. Identified measures of CC are: IT-enabled coordination, inter-professional teamwork and consistency, patient centredness, communication and information transfer, physical infrastructural facilities and requirements, delivery of quality care, and facilitating transitions and accountability. Patient-centredness was found to be the most important construct of CC. Delivery of quality care is the most influenced construct and is affected by all the other constructs. Based on the results, practitioners may develop an overarching strategy to deliver seamless care and better health outcomes. This understanding may help in designing processes which in turn would deliver health as a social good.

Integrated Care: A Pill for All Ills?

There is an increasing policy emphasis on the integration of care, both within the healthcare sector and also between the health and social care sectors, with the simple aim of ensuring that individuals get the right care, in the right place, at the right time. However, implementing this simple aim is rather more complex. In this editorial, we seek to make sense of this complexity and ask: what does integrated care mean in practice? What are the mechanisms by which it is expected to achieve its aim? And what is the nature of the evidence base around the outcomes delivered?

Integrating funds for health and social care: an evidence review

OBJECTIVES

Integrated funds for health and social care are one possible way of improving care for people with complex care requirements. If integrated funds facilitate coordinated care, this could support improvements in patient experience, and health and social care outcomes, reduce avoidable hospital admissions and delayed discharges, and so reduce costs. In this article, we examine whether this potential has been realized in practice.

METHODS

We propose a framework based on agency theory for understanding the role that integrated funding can play in promoting coordinated care, and review the evidence to see whether the expected effects are realized in practice. We searched eight electronic databases and relevant websites, and checked reference lists of reviews and empirical studies. We extracted data on the types of funding integration used by schemes, their benefits and costs (including unintended effects), and the barriers to implementation. We interpreted our findings with reference to our framework.

RESULTS

The review included 38 schemes from eight countries. Most of the randomized evidence came from Australia, with nonrandomized comparative evidence available from Australia, Canada, England, Sweden and the US. None of the comparative evidence isolated the effect of integrated funding; instead, studies assessed the effects of 'integrated financing plus integrated care' (i.e. 'integration') relative to usual care. Most schemes (24/38) assessed health outcomes, of which over half found no significant impact on health. The impact of integration on secondary care costs or use was assessed in 34 schemes. In 11 schemes, integration had no significant effect on secondary care costs or utilisation. Only three schemes reported significantly lower secondary care use compared with usual care. In the remaining 19 schemes, the evidence was mixed or unclear. Some schemes achieved short-term reductions in delayed discharges, but there was anecdotal evidence of unintended consequences such as premature hospital discharge and heightened risk of readmission. No scheme achieved a sustained reduction in hospital use. The primary barrier was the difficulty of implementing financial integration, despite the existence of statutory and regulatory support. Even where funds were successfully pooled, budget holders' control over access to services remained limited. Barriers in the form of differences in performance frameworks, priorities and governance were prominent amongst the UK schemes, whereas difficulties in linking different information systems were more widespread. Despite these barriers, many schemes - including those that failed to improve health or reduce costs - reported that access to care had improved. Some of these schemes revealed substantial levels of unmet need and so total costs increased.

CONCLUSIONS

It is often assumed in policy that integrating funding will promote integrated care, and lead to better health outcomes and lower costs. Both our agency theory-based framework and the evidence indicate that the link is likely to be weak. Integrated care may uncover unmet need. Resolving this can benefit both individuals and society, but total care costs are likely to rise. Provided that integration delivers improvements in quality of life, even with additional costs, it may, nonetheless, offer value for money.

The underlying challenges of coordination of chronic care across Europe

An effective response to the rising burden of chronic disease requires a health system environment that is conducive to implementing structured, integrated approaches to chronic disease prevention and management. This study presents some of the reported factors hindering the successful implementation of chronic care approaches in six European healthcare systems and focuses on processes to address these. We conducted 42 semi-structured interviews with key informants in Austria, Denmark, France, Germany, The Netherlands and Spain, representing the decision-maker, payer, provider and/or patient perspective. Despite differences among the healthcare systems studied, a shared set of barriers emerged. These included: (i) a continued focus on complications management and a failure to integrate risk minimisation and disease prevention along the spectrum of care; (ii) care fragmentation acting as a barrier to better coordination; (iii) a mismatch between intent, at national level, to enhance coordination and integration, and ability at regional or local level to translate these ambitions into practice; and (iv) a lack of structures suitable to promote proactive engagement with patients in the management of their own condition. Findings suggest successful implementation of chronic care across Europe will require cross-disciplinary collaboration, raising the profile of general practitioners and nurses, designing care explicitly around the needs of the patient, and the political will to carry forward these chronic care measures.

From coordinated care trials to medicare locals: what difference does changing the policy driver from efficiency to quality make for coordinating care?

The terms coordination and integration refer to a wide range of interventions, from strategies aimed at coordinating clinical care for individuals to organizational and system interventions such as managed care, which contract medical and support services. Ongoing debate about whether financial and organizational integration are needed to achieve clinical integration is evident in policy debates over several decades, from a focus through the 1990s on improving coordination through structural reform and the use of market mechanisms to achieve allocative efficiencies (better overall service mix) to more recent attention on system performance to improve coordination and quality. We examine this shift in Australia and ask how has changing the policy driver affected efforts to achieve coordination? Care planning, fund pooling and purchasing are still important planks in coordination. Evidence suggests that financial strategies can be used to drive improvements for particular patient groups, but these are unlikely to improve outcomes without being linked to clinical strategies that support coordination through multidisciplinary teamwork, IT, disease management guidelines and audit and feedback. Meso level organizational strategies might align the various elements to improve coordination. Changing the policy driver has refocused research and policy over the last two decades from a focus on achieving allocative efficiencies to achieving quality and value for money. Research is yet to develop theoretical approaches that can deal with the implications for assessing effectiveness. Efforts need to identify intervention mechanisms, plausible relationships between these and their measurable outcomes and the components of contexts that support the emergence of intervention attributes.

Coordinated care: what does that really mean?

The healthcare system in Australia is struggling to meet the healthcare needs of the ageing population. The pressure on health systems to solve these complex problems can create a sense of urgency to find a panacea in concepts such as coordinated care. A common understanding of coordinated care is often assumed when, in reality, the concept is neither clearly defined nor completely understood. The purpose of this review was to examine and identify the attributes of coordinated care to facilitate a shared definition of this concept within the primary care context. The study was a conceptual review of the literature relating to coordinated care in chronic disease. Two key electronic databases (MEDLINE and CINAHL) were searched using terms generated by a panel of primary healthcare practitioners and researchers. Following the application of inclusion and exclusion criteria, 20 studies were selected from an initial pool of 128. Several key attributes of coordinated care were identified together with a definitional statement. Coordinated care in the primary healthcare setting can be broadly defined as the delivery of systematic, responsive and supportive care to people with complex chronic care needs. It relies heavily on complicated concepts such as partnerships, networking, collaboration, knowledge transfer, person-centred practice and self-management support. The expression of these concepts in the literature was relatively superficial, with little discussion of the actual practices that might be implemented in order to enact them. This paper provides a framework of coordinated care within the primary care setting that can guide future work around implementation and evaluation.

Role of specialists in common chronic diseases

Consultant care is currently available to only a small proportion of people with chronic illness. How can we enable many more people to benefit from specialist expertise?