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- Summary
- Outline
- A. Integrated Care
- B. Integrated Care Organisations
- C. What are the Policy Issues Raised by Integrated Care?
- D. Who Needs to be Involved in Developing Integrated Care?
- E. Where to Next?
Summary
Integrated care seeks to deliver health and disability support services to people and to communities in a co-ordinated way – gains in health and independence are achieved by improving services within the funding available.
Integrated care organisations are finding ways to overcome barriers to providing good integrated care. These organisations can take various different forms and may involve different degrees of pooling of funds.
Such developments raise policy issues around both the barriers to good developments and the risks of adverse effects. As these issues are addressed more and more people are likely to be involved in further expansion of integration innovations.
Outline
a. Integrated care
- The problems and key elements of the solution
- Improving co-ordination of services for individuals
- Services based on need and evidence of effectiveness
- Resource allocation
- Effective information and management systems
b. Integrated Care Organisations
- Integrated provider networks and systems
Integration of funding
c. What are the Policy Issues Raised by Integrated Care?
- Promoting desirable developments
- Maori Provider Development Scheme
- HFA Service Integration demonstration projects
- Controlling risks
- Ensuring good value from any different arrangement
- Ensuring fairness
- Ensuring stability and security
- Ensuring choice of ICO
A. Integrated Care
Integrated care seeks to deliver health services to people and to communities in a co-ordinated way; gains in health and independence are achieved by improving services within the funding available. It encourages a “population perspectiveâ€, so that decisions can be made among competing needs including prevention, treatment, and support. It can encompass personal health services and disability support services. Personal health services are delivered to individuals and include both hospital and community-based health services. Services for people with disabilities are designed to support their ability to live independently and interdependently within the community. These services include residential, home support, rehabilitation and environmental support services.
Integrated care arrangements should result in improved outcomes by reducing the divisions between services and bringing the services and their resources together at a local level.
Integrated care offers:
- services to meet people’s needs, and not the needs of the system
- improved co-ordination and communication between different providers so that service is given in the best place by the most appropriate provider with the least possible disruption
- improved quality
- improved continuity
- improved decisions about where health resources are spent
- reduced duplication of administrative and clinical procedures.
1. The Problems and Key Elements of the Solution
Delays, gaps and barriers between components of health and disability care are missed opportunities to meet the common goal of having healthy and independent New Zealanders.
Barriers between the different parts of the system result in missed or delayed treatments or other interventions. And that means that people may suffer longer than they need to, or that their condition may progress irreversibly. Inability to get timely specialist assessment and advice can result in deterioration until admission is inevitable. Poorly co-ordinated community services may delay proper recognition and treatment of a condition such as postnatal depression.
Gaps are also an opportunity for error. For example, the gap between hospital and community carers may mean that the hospital does not take proper account of what is already known about a person’s family circumstances and discharge arrangements are inappropriate.
Where lack of co-ordination leads to duplication between components of care, there is waste of that scarce commodity, the health dollar, that could be put to far better use elsewhere. And where lack of co-ordination leads to gaps which result in not only poorer health but more expensive later intervention, there is also waste.
Comprehensive, well-integrated services are the goal: the right service, to the right person, in the right place, by the right practitioner, at the right time, for the right cost. Does that sound like another definition of quality care? Yes it is. Because a good quality service is integrated. It functions as a united whole, for the person.
Some of the critical elements for good quality, integrated care are:
- improved co-ordination of services for individuals
- services based on need and evidence of effectiveness
- good decisions around resource allocation
- effective information and management systems.
2. Improved Co-ordination of Services for Individuals
Our health care system has some quite significant divisions between its various parts. For example, there is virtually no continuity for patients between care they receive from GPs and practice nurses in the community and what happens when they are admitted to hospital. Other people with complex needs can be seeing a confusing collection of specialist carers and care is often poorly co-ordinated. There can also be confusion and duplication when an individual’s needs span different parts of the health sector such as mental health, disability support and personal health.
Most of the integrated care developments that are beginning around the country have improved co-ordination as their main aim. At the most basic level they involve groups of providers meeting to identify where processes could be improved to lower barriers to access and give individuals using the services a better service. So, for example, a co-ordinated mental health service would bring together all those involved with providing care to mentally ill people in a given population. The aim would be to identify where services are best provided, who should be providing care, and particularly how transitions from one service or environment to another can best be handled.
Clinical pathways, disease management protocols and referral guidelines are all practical tools to help co-ordination and best practice. They are basic information resources, drawn up by everyone involved, that show how the different parts can work better together, for better results for patients.
Solutions will often – though not always – involve identifying a key worker for a particular person or during an episode of need. Case management uses this approach and is especially useful where an individual clearly has complex needs that span several service providers. So case management is, in reality, a form of integrated care.
Other changes may be simply an issue of better communication between parts of the system. The form and key content of referral letters, for example, or the processes to be followed before discharge from hospital back to the community are the sorts of areas that can often be improved.
3. Services Based on Need and Evidence of Effectiveness
Better co-ordination of the wrong services or for the wrong people is not going to achieve anything. Integration must use best practice guidelines and other techniques to enable the greatest gains to be made for individuals and groups. The movement towards fair and effective services has been growing for some years now.
The Disability Support Services (DSS) framework determines the way individuals can access disability support services. Under this framework an individual’s needs are assessed and then services, perhaps from different providers, are co-ordinated to meet the needs from within available resources. The framework recognises resource constraints and the need to maximise independence for the population.
The booking system for elective surgery will ensure that those with greater need are treated sooner. The work on evidence-based guidelines led by the National Health Committee has been gaining momentum, with a dramatic increase in the number of guidelines – and those who know how to use them – in recent years.
The challenge now is to build on that base – developing guidelines in new areas, but more particularly, developing and implementing established guidelines in a way that meets local conditions. The challenge is to find ways to build them meaningfully into daily practice. That will differ from place to place, and must be adapted to the pattern of services on the ground locally.
4. Resource Allocation
The third element of integrated care involves making the best decisions about how to allocate services and resources across a population.
The idea of recent integrated care initiatives has been to look at much smaller population groups and involve both communities and clinicians so that much more responsive and sensitive decisions can be taken. This means that the right services can be made available to the population in a way that achieves the best health outcomes.
While services are based on responding to those who arrive on the doorstep, opportunities to improve the health of those who, for whatever reason, do not come or who appear less often, will continue to be missed.
This means not just doing well for those who attend but improving outcomes for the whole population. This approach, for example, allows a focus on reducing preventable ill health in Maori populations and finding better ways to offer appropriate interventions. Similarly, a proactive stance will limit the approaching wave of ill health expected because of the steady increase in the number of older Pacific Island people.
For example, an organisation that addresses the management of diabetes in a group of, for example, 30,000 people may put resources into identifying undiagnosed cases to allow early intervention and into dietary advice to the whole population. It may decide to fund these new services by shifting some resources from expensive specialist hospital care into the community.
Another group representing a Maori community might favour education programmes and primary care. Such a group may fund these services from the costs saved by avoiding hospitalisation. They might also shift resources from high cost pharmaceuticals into home care, anti-smoking campaigns, or better parenting programmes.
5. Effective Information and Management Systems
Effective information and management systems are essential to enable a network of providers to exchange patient information and to best manage a single contract for an integrated range of services.
The Government has already committed almost $4 million to further develop health information systems through a series of pilots which directly benefit integrated care providers and facilitate their development. Health information systems are crucial to the development and success of integrated care initiatives, and funding for these forms part of the Government’s ongoing commitment to integrated care developments.
A total of 17 health information systems pilots will be funded this year, covering a wide range of initiatives promoting communication between providers, as well as guidelines and other information on the Internet. A number of pilots concentrate on sharing patient information between primary and secondary providers, using electronic data interfaces and Internet-type technology.
These are exciting developments and will result in bringing providers closer together and allowing a more integrated package of services to be delivered. And of course, the sharing of patient information must ensure patient privacy.
B. Integrated Care Organisations
The developments described above are in areas that many excellent providers and academics have devoted their entire professional life to improving. So why has there been this recent flurry of interest in these issues under the new name of integrated care? Because integrated care organisations have the potential to overcome some of the barriers that have made it hard to provide good quality integrated care.
Are there particular ways of contracting or particular organisational forms that make it easier to deliver high quality, effective, seamless services? How can organisations or networks of providers remove barriers to patients getting the right service at the right place from the right person?
Integrated Care Organisations (ICOs) can help bring together practitioners and organisations to make it easier to work together. This could be through a network of providers, a single provider organisation, or the integration of funding in one organisation.
Contracts with ICOs can cover a range of services delivered by several providers with a single pool of funding, using appropriate incentives. The key to success is to remove the barriers to making the best use of available resources and to control financial risk in order to get the best health and independence from the resources available.
1. Integrated Provider Networks and Systems
An integrated network may be a collection of organisations which voluntarily come together to deliver a co-ordinated package of services for their patients. This may be a collection of voluntary organisations, Maori or Pacific Island health providers, professional partnerships, or privately owned groups – those who want to retain their autonomy but work in a co-operative venture for the good of their patients. This style of voluntary partnership is starting to emerge – for example the Christchurch child health project involves Plunket, local Maori groups, a GP practice, an Independent Practitioner Association (IPA), and the public hospital.
An integrated system is a single organisation which provides a very wide range of services. The arrangement of the different parts of a system are voluntary – it is a part of the way that the whole group operates. There are no examples of integrated systems in New Zealand yet.
2. Integration of Funding
Funding can be “pooledâ€, ie integrated. This can remove artificial barriers between different services, based on different funding. In its widest sense, that is what the Health Funding Authority (HFA) is – an organisation which has integrated funding across a wide range of services. It has brought together the old primary care funding and the Area Health Board funding within the personal health ring fence. It has brought together the old Department of Social Welfare funding with the old Area Health Board DSS funding within the DSS ring fence. It has removed the artificial barriers to funding care for individuals, which used to exist. It is now necessary to realise the potential of that integration of funding by following best practice and providing the right service in the right place from the right practitioner.
The range of possible forms for an ICO which integrates funding is very wide. It could be a community-based trust. Developments are underway in Marlborough, through the Marlborough Transitional Health Trust, to look at ways to have significant community as well as local provider involvement in the process of funding all health care for local people.
The ICO could be a provider organisation which delivers some services itself and sub-contracts services from other providers where it does not offer them – such as in some UK total purchasing projects. It could be primary-care based. Alternatively, the public hospital could be the key player with contracts to primary care providers.
The recent UK primary care group approach, and locality commissioning which preceded it, are ways to integrate funding. In the first instance the groups will probably operate as advisory to the health authority that will still carry ultimate funding authority. However, it is envisaged that many groups over time will become autonomous funders.
An alternative is a totally separate organisation which does not provide any services itself, but only contracts for services. This is the type of arrangement that Co-ordinators of Disability Support Services could evolve into.
While form may differ, there is one key element that is likely to be consistent. Any ICO should get a fair share of funding for the people covered by that ICO. In other words, the ICO would be “capitated†(with a fixed amount per head – per capita).
The HFA’s recently announced national strategy for general practice envisages a move to such a system with funding on a capitation basis. Government funding for general practice services will shift from the current fee per visit, to a system of payment based upon the size and nature of the practice’s enrolled population. It is planned to use a funding formula that fairly reflects the health needs of the population taking account, for example, of age, gender, ethnicity, socio-economic status and perhaps chronic disease and disability.
C. What are the Policy Issues Raised by Integrated Care?
The Government actively supports integrated care developments which provide more effective health and disability services. As regulator and dominant funder of the sector, its role is facilitating these developments and removing barriers to gains being made.
The Government needs policy on integrated care developments for two reasons – to promote desirable developments and to protect against undesirable side effects.
1. Promoting Desirable Developments
Integration is already happening and is resulting in better health and disability services. General Practice budget-holding and the emergence of IPAs have brought together general practitioners under different types of umbrella organisations. In the area of disability support services, services are co-ordinated so as to deliver a complete package of assistance to individuals needing support.
As well as the above, the Government has made an explicit commitment to integrated care in the Crown Statement of Objectives which outlines the Government’s overall medium term objectives for the health and disability sector and the performance expectations of the HFA Board. The Crown’s primary objectives are to improve health status; improve, promote and protect the public health; and to promote the independence of the people of New Zealand. In addition the Crown wishes to see Maori enjoy the same level of health as non-Maori. The Government also has an explicit expectation that the HFA Board will “contribute to the initiation and development of innovative arrangements across organisational boundaries that incorporate community views and bring together a range of services to meet people’s needsâ€.
1.1 Maori provider development scheme
The Government has committed funding over three years for Maori Provider Development to support the sustained growth of quality Maori providers of health services and to enhance the ability of Maori providers to deliver effective health services. A key element of the Maori Provider Development Scheme (MPDS) is to improve integration and co-ordination of all health and disability services to Maori. Integrated care initiatives are a high priority in the MPDS for improving access to appropriate and responsive health and disability services. This is expected to lead to improved health status for Maori.
1.2 HFA service integration demonstration projects
By 30 June 1998, the HFA expects to have chosen at least 18 integrated-service demonstration projects covering a wide range of different approaches to integrated services (including three new child and family health team initiatives) to test key questions about integration. The approach is developmental with an evaluation framework intended to enable wider sector learning from the projects. Evaluation studies will examine the contribution of the pilots to improving health and independence. Successful pilots are expected to discover new ways of promoting efficiency, effectiveness and quality.
Pilots are being evaluated against a number of hypotheses, with an overarching goal that the delivery and funding of services should be organised to efficiently and effectively achieve health and gain independence.
There are many excellent proposals for integration emerging around the country. Many will become part of the HFA demonstration projects. Many of the others will not need to be part of the demonstration projects to get support, and should go ahead whether or not they are selected as part of the demonstration project process.
2. Controlling Risks
There is a range of risks that Government will want to see managed. Government’s objectives here will be to ensure New Zealanders get services from integrated care organisations which are at least as good as they would otherwise get, and to ensure that tax-payers’ money is spent prudently.
There will be transition issues, including unbundling the funding and contracts from existing arrangements, and the establishment of fair, risk-adjusted amounts of funding for the populations. As with any significant change, there is a need to handle that change as smoothly and efficiently as can be.
There are a number of quite specific risks that will need to be controlled to ensure:
- good value from any different arrangement
- fairness
- stability and security.
In addition, the question of choice will need to be addressed.
2.1 Ensuring good value from any different arrangement
As the overall objective of the health system is “healthy New Zealandersâ€, it is important that any new arrangements do better than the current arrangements – otherwise it will not be worth the cost, disruption and time needed for the change. In an environment with multiple ICOs, the number of contracts to be negotiated and managed would increase, although the complexity of each individual contract may reduce. It will be important that the benefits (in terms of increased effectiveness and efficiency) obtained from establishing ICOs outweigh any additional transaction costs.
It is likely that most ICOs will have a capped budget for their population, as did Area Health and Hospital Boards. Capping expenditure puts more pressure on volume and quality of service than a fee-for-service approach does. That means that the services offered under new arrangements must be, on average, better than what is available now. Where ICOs are responsible for services, the range of services being purchased on behalf of Government must be defined. Possible options are:Multiple ICOs may extend the range or quality of, or access to, services they offer their enrolled populations and, in doing so, could increase geographical inequities (even if the result is that some people get an even better deal than they do now). Safeguards may also be needed to ensure consistent compliance with the national user-charge regime.
- the Government can specify a minimum set of services. This could be done based upon the work that the HFA is preparing for its service coverage document
- the ICO can be required to detail their coverage. However, this definition would need to be compared with the Crown’s criteria for the general level of service provision.
There would need to be provision in any agreement with a new purchaser to ensure participation in national programmes such as screening and organ donation. In the case of some health promotion and disease prevention programmes, capitated purchasers may have an incentive to participate if, by doing so, they are likely to reduce future expenditure among an enrolled population.
2.2 Ensuring fairness
Government will be particularly concerned to make sure that an ICO could not enrol only the healthy, leaving the costly ill people to be the responsibility of another organisation. The possibility of this sort of adverse selection can be addressed by having a funding formula that calculates an entitlement for each individual based on their expected cost. There will also need to be rules about enrolment. They could be along the following lines:None of these is a perfect way, but all can work as strong controls to ensure fairness.
- open enrolment: a purchaser must accept all comers
- central enrolment: enrolment is conducted through the funder so that subtle influences cannot be used to dissuade perceived high risk individuals
- requirement to pay the costs of a member with an existing condition who changes ICO: this is a subset of the above where costs are potentially huge
- penalties for departure of members: a financial penalty adds an incentive to retain members rather than encouraging them to leave.
2.3 Ensuring stability and security
People will expect to have services which are, on average, at least as good under a new arrangement as under current arrangements. Individuals and communities will also want to have a certain level of stability and security in their ICO.
There are a number of preconditions to be met before allowing any new ICO to become established. Is it and will it continue to be financially viable? What level of financial resources does it have to meet unexpected variations in demand? The ICO will need to demonstrate that it has the expertise necessary to carry out its task.
What about notice of exit conditions including term of notification? Agreement would be required on succession planning where an ICO is to exit from providing a service that was required under either its or the funder’s contract.
2.4 Ensuring choice of ICO
ICOs could be introduced in such a way that New Zealanders would have a choice between two or more ICOs. Another option is that the ICO would have a monopoly on a set of members. An ICO covering a particular geographical area is the obvious example of monopoly.
Many people value the ability to choose for themselves. Competition for members brings choice for individuals.
The ability to choose also means that people can select the ICO that provides the most value for them, and can express dissatisfaction by changing their ICO. ICOs would thus compete to recruit and retain members through the packages that they offer. This customer focus could lead to greater efficiency and consumer satisfaction – as the purchaser who could offer a greater range or higher quality (including appropriate delivery) of services or lower user charges would be able to attract more members and would prosper.
Transaction costs may well be somewhat higher where individuals can choose their ICO. Higher costs would arise through the need to recruit and retain members, administer enrolment, and calculate funding at a more disaggregated level.
Paradoxically, choice of purchaser/plan might diminish choice of providers. This could happen where the purchaser has exclusive (for instance where it is a vertically integrated purchaser–provider organisation or where an ICO enters exclusive contracts to gain a lower price or guaranteed quality) or preferred providers.
While enrolment itself involves costs, these could be minimised by linking to the NHI (National Health Index) number which in turn could be linked to the individual data needed for the continual updating of the risk rating funding formula.
D. Who Needs to be Involved in Developing Integrated Care?
EVERYONE!
There is role for everyone in continuing the development of better, more integrated services. Individual health professionals and care givers need to focus on how they can work better with their colleagues to break down barriers. Referral pathways and the implementation of best practice guidelines need careful preparation and implementation in order to build sensible communication that works across very different localities.
Service managers need to be involved to facilitate the use of management and information systems which support high quality clinical decisions. ICOs which are integrating funding have a great responsibility to manage public funds wisely.
Communities and individuals also have a place. Good decisions on priorities for service changes and the development of best practice guidelines need community participation. Some integrated care arrangements may develop into community trusts. Others will involve community representation in their governance arrangements or steering groups. All integrated care organisations will be expected to demonstrate how they are building their relationships with the community and how they are ensuring effective community participation in the development of services.
The role of the HFA is to support the developments in the health sector. This means walking a fine line – actively encouraging developments in a way that enables all to learn what works well under which circumstances, while ensuring that overall tax-payers’ money is being spent wisely. The HFA need to balance the potential of new developments against the limitations of the current situation, and be prepared to take risks on new, unproven ventures, without throwing all caution to the winds.
The role for the Ministry is again to support developments bubbling up from the health sector, and to support Government in establishing policy that manages the risks posed by integration and ensures delivery of the health gain benefits that integrated care offers.
E. Where to Next?
Integrated care is good quality care. There should be support for processes which enable practitioners and communities to get better health and disability services and which result in better health and independence outcomes.
There are many new developments in the health sector, and many more planned. The huge response to the HFA demonstration project process shows how much energy and enthusiasm there is in the sector for integration. The next step is to take the opportunity to build on that energy, and steadily make progress.
It is not time to rush ahead – there are real risks that have to be taken into account. And if, as progress is made, some risks are so overwhelming that they cannot be managed in a reasonable manner, it may be necessary to abandon particular aspects of integration.
But neither is it time to be so cautious that the opportunity to grasp the benefits is missed. It is time to keep up the momentum, learning from all parties involved, and to begin to reap the health gain benefits that integration has to offer.
