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BRIDGING SOCIAL AND HEALTH CARE - AN INNOVATIVE

FRAMEWORK Pnina Schlaeffer, RN, Rachelle Kaye, PhD, Prof Joshua Shemer, MD

ICIC 2017 - May 2017

Israel National Health Insurance Law of 1995

● Universal compulsory statutory health insurance

● Financed by earmarked and general taxation

● Coverage for health care services is provided by 4 competing

nationwide health plans (HMOs)

● Every citizen must join a health plan but are free to choose and

move from one to another

● Public and private providers of services including physicians,

hospitals, pharmacies and other health care professionals

● Health Plans must provide a defined public basket of services to

all their members

Ministry of Health

Health Plans

Clalit 52%

Maccabi 25%

Meuhedet 14%

Leumit 9%

Hospitals

Acute Care 45 Beds: 14,972

Psychiatric 13 Beds: 3,467

Geriatric 313 Beds: 24,427

Ministry of Finance

The Israeli Health Care System

Maccabi Healthcare Services

A non-profit HMO, with 2.2 million members

Owns and operates selected services such as laboratory,

radiology, nursing, physiotherapy

Contracts with Independent physicians, healthcare

professionals

Contracts with all public acute care and geriatric hospitals

Owns Assuta Medical Centers, the largest private hospital

network in the Middle East

Assuta Medical Centers, Israel

v

Distribution of Facilities Assuta Haifa

Assuta Tel Aviv

Assuta Ha’shalom

Assuta Ra’anana

Assuta Rishon Le-Zion

Assuta Ashdod

Assuta Beer-Sheba Mobile MRI UNIT 2 Mobile Mammography Units

Assuta Ashdod

For the first time in 40 Years

As a result of a new law signed in 2002 and a mega campaign led by the City of Ashdod - Israel's fifth largest city - with a population of 250,000, the Israeli government put out a tender to build a new public hospital

Assuta won the tender in 2011 - the first public hospital in Israel financed, built and operated by a private company.

INTEGRATED CARE VISION

● Innovative, advanced general public hospital, affiliated to a medical school ● Full integration with the community's medical services, meeting the special needs of the patients and their families, both within the hospital and at home ● Integration with Social Services and other support services in the municipality ● All 4 HMOs in Israel have agreed to participate in this model ● The Municipality and the Department of Social Services are committed to this vision

“A Community that has a hospital”

Challenges to Successful Integrated Care • The hospital-community health care DIVIDE • The healthcare –social care DIVIDE

• Communication • Common definitions • Work Processes • Alignment of Incentives • Information Sharing • Interoperability

Integration between Health and Social Care? The Integrated Care Model • Multidisciplinary Staff • At all Points of Care • Working together in total collaboration • Exchanging Up to date data – Person- to-Person and Digitally

For the Good of the Patient

NHS England 2014, Health Policy 2015

Partners- Health and Social Care

Basic Principles - Communication among

Partners

- Technology Infrastructure

Telecare

- Appropriate and Timely

Monitoring

- Real time Data Flow

Enabling Decision -Making

The Health-Social Care Task Force

Ashdod Social Services Disability and Rehabilitation Municipality Health Department Social Security Southern Region

Head Social Worker Department of Social Services and Member Relations

Center for Senior Citizen Rights

Maccabi Healthcare Services

Assuta Director of Nursing – Assuta Network Director of Social Services Director of Nursing, Assuta Ashdod Chief Information Officer, Assuta Ashdod

Task Force Goal

To build a holistic and Integrated model wherein Social

Services, Social Security, Ashdod Assuta hospital and the 4

HMOs will work together to provide efficient and

effective solutions for the Citizen

Objectives

• To join health and social care • To build a holistic and Integrated service concept • To provide timely , efficient service and avoid

duplication • To share information between health and social

care • To develop care pathways in response to patient

needs

Four Target Groups

• Complex Elderly

• Children with Diabetes

• Maternity with Special Care Needs

• Cancer Patients

Action Plan

• Ongoing dialogue between Social Services, Maccabi and Assuta

• Development of Intervention plans for all of the target groups

• Agreement about data interfaces between the of all parties

• Agreement about a shared minimum data set • Patient Consent

Computerized Interface

6

Patient arrives

Personal+Hospital ID#

Captured in Hospital IT

System

Yes + contact person details

Captured in Parallel IT

System

Known to Social Services

NO

Patient Consent

No Yes Telephone Contact

Conclusions • We succeeded in building a patient – centered model that

also meets the needs of each organizational partner • We discovered how very important it is to collaborate with

the Municipality and its services in the care process • We now know we are able to initiate care collaboration

among all of the care services from the entry of the patient into the hospital and to do Collaborative Anticipatory Discharge Planning

• We can now offer the patient many options in the community that we didn’t know about

Conclusions

• We can now assure that the community will be “ready” to care for the patient immediately upon discharge

• We can identify patients who need close follow-up, improve compliance, prevent deterioration and reduce readmissions

• We know we have succeeded - all of the partners have asked for space in the new Assuta Ashdod Hospital so that they can collaborate in the care of the patient “on the spot” and in “real time”

Thank You