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Cor Spreeuwenberg on models of care

by Lloyd Davis

Bio: Dean, Faculty of Health Sciences, Professor, Department of Integrated Care, University Maastricht, Netherlands
Theme: Developing a care model for disease management in Europe

We’ve been discussing the growing number of people with chronic diseases, but i want to focus on morbidity, lifestyle changes, prevention of complications, and changing the role of people with chronic diseases.

The four models to be considered:
Integrated Care
Chronic Care Mode
Kaiser Permanente Model
Disease Management

People are asking whether we can use these in Europe and whether we can work to have one european model and I say we don’t need one.

Integrated Care
Bringing together inputs management and organization together with diagnosis, treatment, rehab and health promotion with an aim at improving services. It’s really the integration of content and structure. We deliver care, but we can’t do that if we don’t pay attention to expertise, infrastructure, academic research and QA.

The Chronic Care Model
Focuses not on patient satisfaction but on functional and clinical outcomes, interactions between a prepared proactive team and an informed activated patient supported by the health system and the community - implies interation at all levels. The background assumption is that better informed patients have better outcomes and so the team have to support self-care, but also measure progress and ensure follow-up and deal with changes in the intensity of care as necessary.

Kaiser Permanente Model
All aspects are integrated - outreach from hospital to commuity, active planning and management, promotion of self-responsibility and self-care, shared care between professionals and each other and with patients and their families. The role of doctros as leaders and organizers of care - they need data to steer care improvements. What is interesting here too is the learning network. The model has a hierarchy but simplified they have 80% who are helped by supported self care. 15% need disease management and then a few have more intensive care management.

Disease Management
Coordinated, health care with interventions and communication for populations with conditions in which patient self-care efforts are significant. Management based on data and information with an aim of efficiency (improving outcomes and ROI).

Comparing these models with Europe, we have to recognize that insurers are public, that innovations focus on providers, that Europe lacks data infrastructure, and expected ROI is less than in USA. The complex relationships between governments, providers, insurers and patients make it easy to escape from ‘letting it happen’.

Some examples:
Sweden - heavily decentralized in counties and micipalities - payment by taxes, small co-payments, low productivity, and less urgency about a need to change.

France - heavily dominated by the state and very centralized. Cheaper facilities limited to 30 chronic diseases. They are taking on the chronic care model but still focus on caregivers, small networks and a small number of initiatives.

England- national system with delegation to regions, a lot of variation, and involvement of private providers. The have also adapted Kaiser Permanente model in many counties. Increasing focus on self-care and self managment.

Germany - 90:10 social to private insurance. Disease Management programs have been introduced step by step, voluntary participation, a lot of cooperation between hospitals and community sector - lots of incentives but physician-dominated and not sure how much active participation of patients there is.

Netherlands - mandatory private insurance this year. “Let 1000 flowers flourish” policy. Since 2006, have implemented Disease Management programs that have to meet requirements to function as contractor, as a motor for restructuring GPs, this doesn’t encourage involvement of medical specialists. Support of self-management still weak. Disease management programs will be introduced in primary care. Prevention and patient participation have developed.

Lessons Learned
Nationalization doesn’t seem to matter, the role of insurers is still weak, there are many helpful decentralized intatives, and I like the mentality of managed competition. The focus lies on influencing providers and not patients. GPS are dominant. There’s room for improvement in self-management, information benchmarks, and incentives.

We’ve developed the Maastricht Chronic Care Model which nicely parallels the Kaiser Permanente model - the majority get treated by GPs and nurses; high risk patients see a nurse specialist and a few see the medical specialist.

We believe and have evidence that we have made the allocation correctly and that it’s effective - the nurses are much better suited to dealing with high-risk patients than the GPs. We’ve seen improved clinical outcomes overall, brought down overall costs, and have more satisfied patients. The results are mainly attributable to nurses. This year, we’ll move to GP contracting, more focus on clinical role of nurse practitioners. Specialist nurses as consultants for practitioners, improving self management, developing instruments and technology.

So I think that Chronic Care Management can be combined with Disease Management. Care patterns must be based on complexity of health problems and readiness of patients for self-management - we need more powerful systems for self management. Physicians may function as consultants for complex situations. And encouraging managed competition between regional providers may contribute to effectiveness and quality of care.


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