There are great examples of integrated care services here locally and abroad.
In Australia, I’ve been impressed by the following providers and programs:
- Institute for Urban Indigenous Health and their Deadly Choices Healthy lifestyle promotions and health assessments tackle social, cultural and lifestyle determinants of health and dovetail with health care services for indigenous populations.
- Wrap around services for patients with drug dependence, such as Fresh Start in WA and Turning Point in Victoria, where a broad scope is considered beyond traditional drug and alcohol services (e.g. housing, mental health, education, carer respite, rehabilitation)
- Coordinated team based care under the Department of Veteran’s Affairs Coordinated Veteran’s Care program, with increased funding and autonomy to primary care clinicians to keep at risk patients at home.
- Mental health workers joining paramedics and police on call-outs in Western Australia, Victoria and NSW – bringing complementary services together to tackle the multiple faceted presentations.
I have also had the opportunity to lead the following projects that support care integration:
- Diabetes Care Project. A precursor test to healthcare homes, additional capitation and pay for performance funding was created for up to 8,000 patients, in addition to proactive care planning and navigation, GP training and specialist case conferencing. Evaluation showed statistically significant clinical improvements in high-risk diabetes patients compared to controls.
- Western Sydney Integrated Care Pilot. Specialist outreach from Westmead hospital for cardiovascular, respiratory and diabetes patients, working with GP clinics and primary care teams. Evaluations pending.
- The first major foray by multiple Australian health insurers and State Governments to integrate care with General Practitioners, targeting the top 5 percent acuity patients that account for over 40 percent of health system expenditure. Linking admissions and insurer data to GP records help locate ‘high utilisers’ to specific GP clinics, and care coordinators and care planning tools were provided to address hospital admission risks. Evaluations are pending but early follow-up show a three-fold reduction in death rates after 2 years.
Internationally, I’ve learnt a lot from other health systems – select examples include:
- Kaiser Permanente, California. Vertically integrated services such as their collaborative cardiac care service, which applies disease registries, evidence-based protocols and team-based collaboration to reduce all cause mortality by 70 percent compared to other providers
- Project Echo, New Mexico. Video-enabled, specialist outreach and case conferences, leading to quality evidence-based care across networks of primary care. This model is now applied in over 60 disease groups across 23 countries.
- Alzira model, Valencia. Public-private partnerships taking accountability for full population health outcomes, leading to reduction in average length of stay in hospital (4.3 days compared to 6 days in other regions in Spain) and 25 percent lower per capital health costs.
- Patient-centred medical homes in the US, such as Geisinger, Community Care of North Carolina, Health Partners, InterMountain and John Hopkins that have demonstrated 15 to 25 percent reductions in hospital admissions, compared to controls.
- Nuka System of Care, Alaska. Customer involvement and holistic approach increased primary care empanelment from 35 percent to 95 percent, and delivered 36 percent reduction in hospital admissions and 42 percent reduction in ED visits, all at over 90 percent patient satisfaction.
- Te Whiringa Ora, New Zealand. Self-management coaching, coordination, care planning and telehealth support for top 5 percent patients, leading to over 50 percent improvement in bed days compared to controls (and $3,416 per annum cost savings)
I have a list of examples twice as long that haven’t worked; let’s examine the common challenges these case studies overcome for success.
- Erica Amon, Presentation to International Foundation for Integrated Care, 2014.
- Grumbach, Bodenheimer, Grundy, Outcomes of Implementing Patient-Centred Medical Home Interventions, Patient-Centred Primary Care Collaborative, 2009.