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DG SANCO Contract Nr : HEALTH-20121209

ACT Programme

Annex A to Deliverable 7

Description of the 5 ACT regions

Due date of deliverable: Month 27

Actual submission date: 1st June 2015

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© ACT Programme Consortium - Public

Annex A to Deliverable 7, version 3.0.


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DOCUMENT INFO

Author(s)

Author Company E-mail

Steffen Pauws Philips [email protected]

Joana Mora Kronikgune [email protected]

Josep Roca IDIBAPS [email protected]

Montserrat Moharra AQuAS [email protected]

Iván Dueñas Espín IDIBAPS [email protected]

Documents history

Document version #

Date Change

V0.1 30-04-2015 Starting version, template

V1.0 14-05-2015 Final version

V2.0 26-05-2015 Updated version with expanded info on regions

V3.0 31-05-2015 Approved Version to be submitted to EU

Document data

Editor Address data Name: Josep Roca Partner: IDIBAPS Address: Villarroel,170 – Barcelona 08036 Phone: +34-93-227-5747 Fax: +34-93-227-5455 E-mail: [email protected]

Delivery date 1st June 2015

Keywords

Keywords Chronic Care; Health Risk Prediction; Integrated Care; Patient Stratification; Population Health

mailto:[email protected]

mailto:[email protected]




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Table of Contents

1 THE 5 ACT REGIONS .......................................................................................... 4

1.1 Basque Country ....................................................................... 4

1.2 Catalonia ................................................................................... 8

1.3 Lombardy ............................................................................... 14

1.4 Groningen ............................................................................... 17

1.5 Scotland .................................................................................. 19

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1 The 5 ACT regions

1.1 Basque Country

The Basque Country (Euskadi; capital: Bilbao) has a universal health insurance system (Spanish General Healthcare Act: 1986) which is financed through general taxes. There is a capitation-based payment system to address both equity and efficiency. Co-payment can occur for medication in outpatient care. Besides the public insurance there is also a supplementary private insurance possibility that arrange access to private health centres. The central Spanish government takes care of basic legislation, general health policy, finance and minimum healthcare coverage package. The Basque Country acts as an autonomous health care region for its organizational structure, accreditation, purchasing and service provision, amongst other things. The Basque public healthcare provider is Servicio Vasco de Salud-Osakidetza (acronym: OSAKIDETZA). All the public hospitals and primary care centers of the Basque Region are under this governmental organization. The Basque Health System includes 320 primary care centers, 14 acute hospitals (4,278 beds), four sub-acute hospitals (524 beds), 4 psychiatric hospitals (777 beds) and 2 contracted long term mental hospitals. Osakidetza has a target population of more than 2 million inhabitants. Currently, aging and chronic conditions account for 80-% of the medical consultation in the Basque Country taking 75% of the total health budget. More than 19% (>400,000 inhabitants) of the total population is older than 65 years. Some relevant socio-demographic data are shown in Table 1.

Table 1. Socio-demographic data from the Basque Country.

Socio-demographic data Euskadi–Basque Country

EU -27

Population (no, inhabitants) 2,172,175 499,753,500

Population density (inhab/km2) 300.2 117.8

Life expectancy (years) - Men 77.2 76.1

Life expectancy (years) - Women 84.3 82.2

Hospital beds (per 100,000 inhabitants) 375 590

Internet access (% homes) 60 65

Per capita GDP (EU 27= 100) 136 100

Population aged between 20 and 24 with secondary studies (%)

78.0 78.5

Socio-demographic data Euskadi–Basque Country

EU -27

Population (no, inhabitants) 2,172,175 499,753,500

Population density (inhab/km2) 300.2 117.8

Life expectancy (years) - Men 77.2 76.1

Life expectancy (years) - Women 84.3 82.2

Hospital beds (per 100,000 inhabitants) 375 590

Internet access (% homes) 60 65

Per capita GDP (EU 27= 100) 136 100

Population aged between 20 and 24 with secondary studies (%)

78.0 78.5

Osakidetza is fully involved in the regional strategy to tackle the challenge of chronicity1, which implies the transformation of the health care provision model. The new model represents a radical move away from the current healthcare and management model characterized by a high degree of fragmentation, a lack of coordination between healthcare levels and the inability to provide an optimal continuity of care required for good management

1 http://cronicidad.blog.euskadi.net/descargas/plan/ChronicityBasqueCountry.pdf

http://cronicidad.blog.euskadi.net/descargas/plan/ChronicityBasqueCountry.pdf




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of chronic patients. Elements and changes have been introduced to enable the navigation towards the new model (see Table 2).

Table 2. Changes required in the current provision model.

The changes to the healthcare model have created and changed structures, processes and tools, pretending to increase coordination among healthcare professionals and social workers, responding to the health and social needs of patients and providing a high degree of effectiveness, efficiency and health outcomes. This transformation is designed to bring about a proactive, highly patient-centered system, providing patients with all the necessary support for optimum self-management of their illness and to prevent other ailments. To fight chronicity, the Basque Country has organized its local healthcare system by demarcating eleven so-called Integrated Local Health Systems or microsystems geographically (see Figure 1). They represent sub-regions within the Basque Country: Ezkerraldea, Araba, Interior, Uribe, Treviño, Bajo Deba, Alto Deba, Goierri-Alro Urola, Gipuzkoe, Donostia and Bidasoa. Each microsystem has its own population for which care for long-term conditions is coordinated amongst all health and social partners and organizations including public health organizations, primary care, specialized care, care for sub-acute patients, mental health and socio-health.




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Figure 1. Distribution of integrated local health systems – Microsystems in the Basque Country.

Within each microsystem, the population is stratified using a risk assessment method based on John Hopkins ACG PM2 (Adjusted Clinical Groups Predictive Model). Risk factors included are demographics, clinical diagnoses (Dx coding), medication utilization (Rx coding) and prior healthcare costs. The output of the risk assessment is a risk score (IPR: Risk Prediction Index) that is used to allocate patients in four different risk strata and programs for ‘case management’, ‘disease management’, ‘self-management support’ and ‘prevention and promotion’ (see . Each microsystem has developed its own adapted Population Intervention Plan (PIP) for patients with multiple comorbidities (‘frailty’) and patients with COPD, HF and type II DM with a total target population of 51,412 patients with the following distribution characteristics: 6,930 ‘frail’ patients with pluri-pathology, 9,435 COPD patients, 12,916 CHF patients and 22,131 diabetes patients3.

2 http://acg.jhsph.org/ for John Hopkins ACG Predictive Modelling

3 In Spanish: DM – Diabetes Mellitus / EPOC - Enfermedad Pulmonar Obstructiva Crónica (COPD) / IC -

Insuficiencia Cardíaca (heart failure) / PPP – Porcelana PluriPatología (frailty & co-morbid)

http://acg.jhsph.org/




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Figure 2. Population Intervention Plans (PIP) in the Basque Country

The population-based predictive modelling tool classifies all residents in the Basque Country with public insurance (this is, almost all the inhabitants of the autonomous community) and offers estimation of individual health care services usage for the forthcoming 12-month period (costs is the dependent variable).

Co-variables included in the model include hospital costs, pharmacy costs, co-morbidities (from Adjusted Clinical Groups, ACG) and other information that has been recorded by health professionals (mainly electronic medical records and other computerized files). Importantly, previous hospitalizations (not including hospitalization due to traumatisms) are explanatory, so it is possible to make a separate analysis of past-history of hospitalizations. Socio-economical characteristics of the citizens are also considered in the modelling, but they do not add a significant additional predictive power.

Basically, it is a linear regression model (although other types of regression analyses were tested according to different dependent variables; namely, negative binomial, multilevel, etc.), nevertheless complex regression analyses had an explained variability similar than simpler models, so linear regression was finally chosen. The model is used to run predictions with the entire population dataset, but also for specific subsets like COPD patients, Diabetic patients, and those with chronic heart failure. Main statistics characterizing the model are a PPV of 23.2%; sensitivity of 45% and ROC-AUC of 0.80.




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Predictions from the model for each citizen are reported into the clinical records and are available to practicing physicians, but functionalities to perform specific queries are still under development.

Main concerns regarding the approach are those related with the transferability of the predictive tool to other areas, as well its potential to evolve toward a comprehensive patient-base risk assessment tool. The analysis carried out seems to indicate that both flexibility and potential to evolve of the current tool is technically feasible provided that limitations associated to current ACG licenses are properly managed.

1.2 Catalonia

Catalonia (Catalunya, capital: Barcelona) has a universal health insurance system (Spanish General Healthcare Act: 1986) which is financed through general taxes. There is a capitation-based payment system to address both equity and efficiency. Co-payment can occur for medication in outpatient care. Besides the public insurance there is also a supplementary private insurance possibility that arrange access to private health centers. The central Spanish government takes care of basic legislation, general health policy, finance and minimum healthcare coverage package. Catalonia acts as an autonomous health care region for its organizational structure, accreditation, purchasing service provision, amongst other things. The Catalan Health System includes 400 primary care centres, 63 public in-patient acute hospitals with outpatient clinics and 56 emergency rooms (13,167 beds). Catalonia has a target population of 7,503,118 inhabitants with a total functional health care budget of about 11.4 billion euro (in 2011, about 30% of total Catalonia Government budget), which amounts to about 1500 euro per capita public expenditure. As shown in Figure 3, Catalonia consists of seven districts. The distribution of the Catalan population varies across districts. As shown in Table 3, the vast majority (66%) of the population lives in Barcelona. The Catalan Health Service (Servei Català de la Salut: CatSalut) is the public service care provider organization and health insurer. CatSalut plans, purchases and assesses health services according to the health needs of the population. It purchases services from its various service providers through the use of contracts which state the health objectives and the service being bought. The Catalan Agency for Health Information, Assessment and Quality (AQuAS) is a public non-profit company reporting to the Catalan Health Service; it offers support to the Catalan health system by means of rigorous scientific knowledge on disease prevention, health and quality of life of the Catalan people. CAHIAQ is member of the ACT consortium.




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Figure 3. Seven districts (sub-regions) in Catalonia.

Table 3. Catalan population of reference by district (2011-2012)

District 2011 2012

Alt Pirineu i Aran 69.457 68.688

Lleida 367.748 368.086

Camp de Tarragona 593.997 596.328

Terres de l’Ebre 188.573 187.359

Girona 845.942 845.142

Catalunya Central 517.831 517.477

Barcelona 5.029.329 5.018.722

Without attributing district 13 11

Total population 7.612.890 7.601.813 Source: Catalan Health Service

There are several currently running health programs in Catalonia. In 2012, The Catalan Ministry of Health and the Ministry of Social Welfare and Family (see Catalan Health Plan 2011-20154) has launched the Program for Prevention and Care of Chronicity (PPAC) to

4 For ‘Health Plan for Catalonia 2011-2015, Generalitat de Catalunya, Departament de Salut, Barcelona, 2012’

see:




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provide a new model of health and social care for the Catalan people with long-term conditions like heart failure (HF), COPD and diabetes mellitus (DM). It should be capable to respond to the chronicity and independent aging challenge by enhancing health promotion and reducing risk factors for the incidence of these long-term medical conditions. It includes

Boosting an active, autonomous and healthy lifestyle. In Catalonia, there is already a deployed health promotion plan (PAFES - Plan of Physical Activity, Sport and Health) for primary health-care services which is based on prescribing and advising physical activity;

Integrating primary and acute health care with social care, for instance, by allowing follow-up chronic patients through primary care;

Recognizing the role of social care provider and family;

Responding appropriately to health and social needs of people with a long-term medical condition;

Evaluating the delivered health care service in terms of indicators. Inclusion of patient to the PPAC program went throughout the year of 2012 resulting in approximately 6000 CPOP, HF, and DM patients.

Figure 4. The Catalan risk pyramid and dedicated health plans. Adopted from Catalan Health Plan 2011-2015.

The Catalan Health Plan has also as a 2015 ‘Patient stratification’ objective to identify the risk profile of the entire Catalan population and record the progress over the two previous years. The population has been traditionally stratified into clinical risk groups (CRG) based on the datasets described in the figure below. However, Catalonia has recently developed its own system (GMA) described in detail below.

http://www20.gencat.cat/docs/salut/Home/El%20Departament/Pla_de_Salut_2011_2015/documents/arxius/he

alth_plan_english.pdf




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Main characteristics of the Catalan dataset.

The Catalan dataset contains data from 7.8M inhabitants, including use of healthcare resources, incidence and prevalence of key disorders and adjusted morbidity groups. The current population-based GMA risk prediction model is updated every 6 months for population risk assessment and stratification purposes using the Catalan dataset. The summary characteristics of the Catalan dataset are depicted in the figure. It is of note that the Clinical Information Table shows limitations for extensive longitudinal studies using machine learning techniques, because it has just recently been set-up as an articulated dataset within the regional network in Catalonia.

The GMA prediction tool - The stratification tool of Catalonia is a descriptive (explanatory) linear model which estimates the risk of hospital admission and death in the next 12 months. Explanatory variables used in the modelling tool are obtained from the dataset described in the figure above. GMA tool is a proxy of the concept of the pyramid of the Population Strata of Kaiser Permanente conceptual frame. The explanatory variables used in the model are: age, sex, mean socio-economical status of the area wherein the patient is living, accessibility to complex services and co-morbidities by the GMA, urgent visits, and number of hospitalizations.

The new tool has been validated using clinical criteria as a comparator. Clinicians used the model as a tool for estimating the risk of certain outcomes, but the model explained better the estimation of admissions, and clinicians estimated better the number of clinical visits. According to the technical report, the variables with a higher power of prediction were: hospital services usage in the last year. When only age and sex are used in the model, the explained variability of the whole model was low, but when information from the co morbidities grouper was added, the explained variability increased.

The GMA prediction model seems to show high potential for transferability. Its use will be expanded to thirteen out of the seventeen autonomous regions in Spain. Moreover, it has potential to evolve toward a comprehensive patient-based risk prediction tool, as explained in Annex F (Net-Health proposal).




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GMA implementation in Catalonia

In this subheading, we summarize the explanatory message to practicing clinicians that has been displayed this 19 May 2015 in clinical workstations in Catalonia to introduce GMA as for clinical application.

CRG GMA

Adaptability No Yes

Validated Yes Yes

Economical cost High Acceptable

Clinical specificity Yes Yes

Complexity/Individualized severity

No Yes

Complexity/Severity per groups

Yes Yes

General characteristics of the GMA:

1. GMA is a new tool which stratifies the population and identifies patients by health risk. It is a

morbidity grouper which allocates patients into one risk group, which let to make a better

management of the patients, especially in the case of chronic diseases, making a better

adjustment of the health indicators.

2. It is more flexible and adequate than the CRG previously used. It`s been created in Catalonia

and it`s been generated from our information, so, it`s more tailored to our needs rather the

CRG (especially in the management of chronic patients). The CRG is based in the health

system from USA, which is very different to ours.

3. Makes an individualized identification. The CRG offers less specific results which are not at the

patient level; the GMA, conversely, assigns an indicator of complexity (risk) by an

individualized manner.

4. GMA assigns a clinical label to each patient with the profile of the multi-morbidity to each

patient. This label it is no specific for each patient. but it has more flexibility than CRG. 5. It improves efficiency

Patients are stratified in seven groups of morbidity

7 Morbidity groups

Patients with active neoplasms

Patients with a chronic disease in 4 or more systems

Patients with a chronic disease in 2 or 3 systems

Patients with a chronic disease in 1 system

Patients with an acute diseases

Pregnancy and delivery

Healthy population




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And, additionally, it classifies each group of morbidity in five levels of complexity

Group of morbidity Complexity Level

Mu

lti-

mo

rbid

ity

Patients with active neoplasms 1 2 3 4 5

Patients with a chronic disease in 4 or more systems

1 2 3 4 5

Patients with a chronic disease in 2 or 3 systems

1 2 3 4 5

Patients with a chronic disease in 1 system

1 2 3 4 5

Patients with an acute diseases 1 2 3 4 5

Pregnancy and delivery 1 2 3 4 5

Healthy population 1

The risk strata are calculated from complexity which GMA assigned to each patient. It`s been identified four strata according to the next criteria:

GMA-1 or low risk stratum: it corresponds to the 50% of the population, with a lower

complexity level.

GMA-2 or moderate risk stratum: it corresponds to the 30% of the population, which is over the

complexity of previous risk stratum.

GMA-3 or high risk stratum: it corresponds to the 15% of the population, which is over the

complexity of previous risk stratum.

GMA-4 or very high risk stratum: it corresponds to the 5% of the population, which has the

higher complexity level.

Stratification of the population from GMA

Mortality Admissions Expense

26.8% 171% 14.125 € 15%

7.5% 56% 5.804 € 40%

1.2% 20% 2.353 € 65%

0.2% 7% 741 € 93%

0.1% 1% 141 € 100%

This population stratification, from a pyramidal perspective, has an inversely proportional relation with mortality, admissions and expenses attributed to the patients; so, could have a predictive value: the higher the level the patient is (in the pyramid), the higher expenses, severity, mortality and risk of admission the patient has. The colours have different meanings (being the green the healthier, and the red the maximum risk of admissions and the higher mortality risk).




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At the ECAP (clinical workstation for primary care physicians), the information from GMA is represented at the superior part of the screen of the clinical workstation. By clicking on the bar, additional information on the past-history of use of resources for the patient is provided.

GMA together with information on admissions allow estimation of the individual risk for each patient (colour) that is associated to his/her allocation into the pyramid stratum. The GMA and admissions data are generated by CATSALUT, and both of them are updated with the same periodicity (approximately each six months). The information is regularly updated into the regional shared health record (HC3).

Stratification in Catalonia: summary for D7

The consolidated Catalan classification of health risk strata used for both service commissioning and clinical applications is the GMA (Adjusted Morbidity Groups) described above. The GMA contains 7 categories of morbidity and each of them has 5 levels of complexity. For clarification purposes, we would like to briefly indicate the different risk assessment/stratification approaches mentioned for Catalonia in the current document, namely: GMA - Consolidated classification in Catalonia, as described above and extensively mentioned in the text of the main document (7 morbidity groups and 5 levels of complexity in each morbidity group) CRG - Risk prediction tool used up to early 2015, briefly indicated in the text MSIQ - Eleven categories elaborated using CRG. Information of stratification using this approach is indicated in Annex E BSA – Classification generated and used by one Catalan provider (Badalona Serveis Assistencials). It is based in four risk strata. BSA is currently also under the GMA system These different classifications reflect that the entire process of population-based stratification is quite dynamic. The phenomenon is similar in other ACT regions like Scotland and Lombardia. The Catalan evolution also indicates that convergence among areas is possible if flexible/dynamic risk prediction tools are used. The GMA system will be applied in thirteen out of the seventeen Spanish regions.

1.3 Lombardy

Lombardy (Lombardia, capital: Milan) is one of the 20 regions in Italy. In 2007, 9,545,441 million people lived in Lombardy, with about 19.7% of its population above 65 years of age and about 27.5% being diagnosed with a chronic condition. Lombardy is divided into 12 administrative provinces (see Figure 5). In 1997, Lombardy was the first Italian region with the setting of a so-called quasi-market model in its local health care system; it has introduced competition to improve quality and control expenditures. As a consequence, the four main




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principles of the Lombardy health care system are universal coverage (solidarity), a separation between health care purchasers and providers, a competition between public and private accredited providers in the presence of a third part payer and patients’ liberate choice between providers.

Figure 5. Lombardy has 15 local health authorities. There are 12 Lombard provinces; the capital Milan is divided into four distinct local health

authorities.

The Lombardy Region raises and manages funds for health care, plans activities in cooperation with so-called Local Health Authorities (LHA or ASL; see Figure 5) and monitors the delivery of minimum levels as defined by the central Italian Government. LHAs (15 in total) manage health care in a geographic region within Lombardy, through smaller units called Districts (86 in total), and contracts volume and kind of services with providers; LHAs are the purchasers of care. Each District manages the care of about 40,000 up to 100,000 people. Providers – either public, not for profit or private accredited - compete on production following the same rules. LHAs are paid by Lombardy through weighted capitation using previous expenses, demographics and geographical criteria, while providers are financed by LHAs on a fee for service basis: prospective DRG (Diagnosis Related Group) payment for hospital discharges, and tariffs for outpatient services. Revenues for Lombard health care fund raising are collected through Governmental (VAT) and regional taxations; any deficit is covered by copayment. Lombardy is able to control its balance (21.177 million euro in 2008) to break even. In short, Lombardy act as an autonomous region, with insurance and funding functions, the LHA with programming and purchasing power, while production is performed by providers. Lombardy has implemented a DRG (Diagnosis Related Group) prospective




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payment for hospital activities as reimbursement model. In 2007, Lombardy has 29 public hospital firms, each managing several local hospitals (97), 73 private accredited hospitals and 23 academic hospitals (IRCCS - Istituto di Ricovero e Cura a Carattere Scientifico), summing to a total of 220 hospitals. The total bed count is 33.7 per 10,000 inhabitants for acute cases and 6.4 for long-stay. The total count of GPs is 8,120. As the Lombard health care system is centered on acute care and secondary care (hospitals), the Chronic Related Group (CReG) program has been initiated to ensure coordinated care to chronic patients, especially those with conditions COPD, heart failure, heart disease, diabetes type I and II and hypertension. Chronic patients (27.5% of the Lombard population) spend about 70% of the total health care budget. In the CReG program the chronic patient will be maintained ‘on care’ by means of a personalized care plan which is resolved by coordination between hospitals and primary care. To establish this coordination, a set of predefined resources (tariffs) are assigned to a service provider to ensure the delivery of care coordination plans to patients. A CReG service provider is a newly formed institutional subject, usually a group of cooperative GPs that has the care delivery responsibilities to assigned chronic patients. Telbios5 is subcontractor for four of the main

GPs’ cooperatives in Lombardia, managing approximately 60% of the chronic patients enrolled in the CReG program.

Figure 6. The CReG class ‘K23’ codifies a patient suffering epilepsy as ‘most costly’ pathology ‘K, diabetes as ‘second most costly’ pathology coded as ‘2’ representing the cost-rank distance between ‘epilepsy’ and ‘diabetes’, and hypercholesterolemia which makes the

total number of pathologies of ‘3’. Inhabitants are eligible to the CReG program on the basis of criteria on payment exemption, hospital use, drug consumption and outpatient service utilization. First-pass stratification on health care cost risks is done by allocating eligible persons to a CReG class which represents

5 Telbios is a telehealth service provider, it has a wide experience in the design and realization of programs

and services to manage new pathways of care for the main chronic diseases and assistance of the patient at

home. It runs the CReG program with over 30 authorized GPs.




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a coding of the patient ‘most costly’ pathology, a cost-rank distance between the ‘most’ and ‘second most costly’ pathology and the total number of pathologies (see Figure 6). The patients managed by Telbios have also the possibility to be included in a case management program, which implies the provisioning of TeleHealth services. The decision to assign patients to the case management option is done through a further stratification on service delivery level by calculating a health risk as a total score sum of coded patient age (0-3), number of pathologies (1-3), main pathology (1-3) and pathology severity (1-3). Based on this sum score, patient are assigned to a case manager (score >=10, 5% of all eligible patients), coordinated care (6-9; 32% of all eligible patients) and customer care (<=5; 63% of all eligible patients). A telehealth service is provided to the top 5% case manager service delivery level. For a patient to be enrolled to a specific treatment plan, he needs to be allocated to a CReG class and his GP needs to be affiliated to an authorized CReG provider. The patient GP then assigns a patient to a plan in a shared decision process. Several health programs are in-place:

1. a disease prevention/lifestyle/self-care program with patient education on lifestyle and self-care of their diseases including a care plan containing the time schedule of exams, GP visit appointments and self-measurements, a welcome kit of a lifestyle manual and a medication diary and an optional 15-hour patient empowerment training course. In 2013, a welcome kit and a care plan education are provided to the full CReG population managed by Telbios and 30 patients concluded the patient empowerment training course.

2. a long term/hospital prevention/chronic care program with patient activation in care program, patient adherence enhancement to care pathway, disease progression monitoring and relapse prevention. A personalized care plan customized by the GP is provided to the patient including vital sign measurement, lab analysis, planned outpatient visits and a telehealth service to be monitored by a medical service center (Telbios). At the end of 2012, this program involved 61,399 chronic patients, over a total of 110,312 eligible.

3. A palliative/ambulatory intensive program with disease progression monitoring and relapse prevention including a telehealth service monitored by a medical service center (Telbios). In 2013, a pilot with 90 patients started for this program.

Plans for developing a population-based risk predictive modelling tool are in place, but they are in an early phase of development.

1.4 Groningen

Groningen (capital: Groningen – Grunnen) is one of the twelve provinces in the Netherlands. It is amongst the smallest and most sparsely populated Dutch regions containing 23 municipalities, located in northern Netherlands with 582,161 inhabitants (as of 2012), a third of which lives in the eponymous capital Groningen. Dutch provinces form the governance structure between the Dutch Hague’s government and local municipalities. For instance, provinces decide on regional healthcare infrastructures whether an existing hospital should be maintained or merge with others.




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Figure 7 The province of Groningen in Northern Netherlands and the location of UMCG and its reach out area for highly specialised treatment

delivery.

The Netherlands has a partially publicly funded (dual), multi-payer, universal health care system. The Dutch government acts only as a regulator for quality and universality of care. A basic and essential insurance package is compulsory for every individual and provided by private insurances; the government sets down the package and ensures universality of care by extra risk-adjusted finance schemes. It is paid for with a flat-rate premium (nominal premium) for the basic package to the selected insurer and salary deductions collected by the Health Insurance Fund (CVZ) for organizing the finance for risk adjustment. There is an option for every individual to buy supplementary cover for procedures outside the basic package. There is a compensation (i.e., ‘zorgtoeslag’) for those with a low income. However, the care for patients with long-term conditions is completely under governmental control; it is regulated by the Exceptional Medical Expenses Act (AWBZ). It is paid for with salary deductions and supplemented by a government revenue grant. Reimbursement is on a case-mix basis using DBCs/DOTs but still has a fixed budget component. DBC stands for Diagnose Behandel Combinatie (Diagnosis Treatment Combination) and consists of the whole of medical services that stems from the demand for care for which the patient consults the specialist. DBC has recently been simplified by DOT (DBC Op weg naar Transparantie/DBC on its way to transparency). Since its reform in 2006, the Dutch reimbursement model underwent and is still undergoing changes to stimulate price competition. Its efficiency and fraud-sensitivity are currently under public debate. In a casemix-based or bundled payment scheme, like the Dutch one, a care provider receives a fixed payment for each case that reflects a bundle of health services, classified into specialty and costs. The unit of reimbursement is a specific case. The payment is set prospectively and not based on actual costs. More precisely, there are two parallel funding regimes, corresponding with segment A and segment B. In segment A, tariffs of the DBCs are regulated by the national tariff agency (NZa) allowing no price competition. In contrast, for segment B hospitals and insurers can negotiate DBC prices including agreements on the volume of medical care. Since the use of segment A in the DBCs has still a fixed budget character which makes it essentially a hybrid funding scheme. A casemix-based scheme has a financial incentive to fight unnecessary services, as cost control is per case. If telehealth is proven to be both a cost-saving and effective option per stratified patient case, it can nicely fit into a casemix-based scheme on a segment B basis (local price negotiation and volume of




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care agreements). Unfortunately, the efficiency and fraud-sensitivity of the Dutch reimbursement system are currently under public debate. More than 90% of Dutch hospitals are owned and managed on a private not-for-profit basis, with about 70% of the specialists working on a self-employed basis (working together in private corporatives without legal personality: ‘maatschappen’). Specialists at university hospitals are often on the payroll. The most important hospital in the Groningen region is the University Medical Center Groningen (UMCG) with an annual budget of 900M euro, with roughly 32,000 admission and 500,000 outpatient visits per year. As one of the eight university Dutch hospitals, it provides the highly specialized medical treatments for the whole of the Northern Netherlands (see Figure 7). Together with the twelve general hospitals, it offers 5,295 beds to the Northern Netherland’s population. General Practitioners (GP) play a coordinating role within the Dutch healthcare system. Every citizen is obliged to register with a GP with freedom of choice. Visiting a specialist is only possible after referral from a GP (or post-referral from another specialist). There are 915 GPs in the Groningen region. The Groningen region is ambitious in deploying a single care platform for the population in Northern Netherlands, allowing for an integrated care delivery with a network of healthcare organisations, external partnerships and research translation embedding. One of the components is a unified web-based patient portal facilitating appointment making, prescriptions, health data management, health education and a self-care agenda for chronic diseases. Within the Dutch, governmental funded foundation ‘Care within reach’ (Zorg binnen bereik), an e-Vita platform is developed for COPD, diabetes and heart failure patients together with industry, insurance and clinical partners. COPD started in 2014, diabetes is ready for roll out and a pilot is running in the Scheper Hospital in Emmen (city in the Province of Drenthe; 180,000 inhabitants) with 150 heart failure patients. The Scheper hospital is running one of the most successful integrated care delivery programs for heart failure patients with full-scale telehealth deployment in the Netherlands demonstrating significant reduction in mortality and readmission rates.

1.5 Scotland

The district in Scotland that participates in ACT is West Lothian. West Lothian council (Scots: Wast Lowden, Scottish Gaelic: Lodainn an Iar) is one of the 32 Local Government council areas of Scotland (see Figure 8). It borders the City of Edinburgh, Falkirk, North Lanarkshire, the Scottish Borders and South Lanarkshire (i.e., the midst of Scotland). The total population of Scotland is 5,295,000 inhabitants (as at March 2011) with a 7.3% unemployed. There are 4,859 GPs available. The 225 publicly owned hospitals offer 24,380 beds. The health and social care system in the whole of Scotland is a devolved responsibility which is overseen directly by the Scottish Government’s Health and Social Care Directorate, who are responsible for overseeing NHS Scotland and delivering the Healthier Strategic Objective which aims to help people to sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to health care.

http://en.wikipedia.org/wiki/Scots_language

http://en.wikipedia.org/wiki/Scottish_Gaelic_language

http://en.wikipedia.org/wiki/Council_areas_of_Scotland

http://en.wikipedia.org/wiki/Scotland

http://en.wikipedia.org/wiki/City_of_Edinburgh

http://en.wikipedia.org/wiki/City_of_Edinburgh

http://en.wikipedia.org/wiki/Falkirk_(council_area)

http://en.wikipedia.org/wiki/North_Lanarkshire

http://en.wikipedia.org/wiki/Scottish_Borders

http://en.wikipedia.org/wiki/South_Lanarkshire

http://www.scotland.gov.uk/About/Strategic-Objectives/healthier




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The Directorate also allocates resources and sets the strategic direction for NHS Scotland and is responsible for the development and implementation of health and social care policy. Its primary responsibilities include finding the best way to develop, support and mobilise the health and social care system in Scotland to deliver the highest quality of health and social care services to people in Scotland, whilst working towards a shared vision of world-leading safe, effective and person-centred healthcare.

Figure 8. West Lothian council in Scotland.

All the available evidence suggests that an integrated care model approach provides greater benefits for people with care needs which are a consequence of chronic conditions, frailty or deteriorating health at the end of life. NHS Scotland is responsible for ensuring that everyone in Scotland receive the health services that they need, and Scotland has an integrated healthcare system with all hospital and community health services delivered by 14 single regional Health Boards. Regional health boards have established 40 Community Health Partnerships (CHPs) to deliver services on the ground. The CHP’s work in collaboration with 32 Local Authorities who are responsible for social care, support, housing, education, environmental and community planning. Scotland has also embarked on the integration of health and social care services across the country to deliver safer, more effective and person centred care; under the legislation currently being developed, NHS Boards and Local Authorities will be required to set up a Health and Social Care Partnership. This will cover, as a minimum, a single Local Authority area and replace current CHP arrangements. The NHS Board and the Local Authority will devolve an integrated budget to the Partnership, made up from primary and community health, adult social care and some acute spend. All Partnerships will be asked to deliver and report on national outcomes, underpinned by a number of performance indicators. The provision of health and care services in Scotland is governed by a number of legal frameworks and guided by strategy and policy designed to ensure sustainable services which are safe, effective and person-centred. The Health and Social Care Directorates Management Board aims to provide strategic leadership for NHS Scotland as well as providing a visible leadership for the Scottish Government Health and Social Care Directorates.

http://en.wikipedia.org/wiki/Scotland




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Scotland currently spends approximately £4.5 billion of public funding each year on health and social care for those over 65 years across the whole country. Well over half (60%) of this is spent on providing institutional care in hospitals and care homes (and almost one-third on emergency admissions to hospital). Although Free Personal and Nursing Care was introduced in Scotland in July 2002, less than 7% is spent on home care in spite of our vision that older people should be helped to remain at home or in a homely setting for as long as possible. Personal care services are provided by local authorities free of charge to those people aged 65 and over in their own home. Nursing care for people at home is provided by the NHS and is free at the point of delivery regardless of age, as is all care provided by the NHS (including prescriptions). Under legislation, local authorities may charge a small fee, depending on the individual’s ability to pay, for non-residential and domiciliary care such as day care, lunch clubs, meals on wheels, community alarms and help with housework and shopping. With the formation of West Lothian Community Health and Care Partnership (CHCP) in 2005, NHS Lothian and West Lothian Council joined forces to continue this tradition by bringing community based health and social care services closer together wherever possible and working in partnership to deliver more accessible, integrated and high quality services which are jointly planned and community-focused. The CHCP has recognised the importance of investing more broadly in preventative services and is facing up to the need to introduce radical changes in the way health and social care is delivered.

Due to the increasingly elderly population, the need to avoid emergency hospital admissions and to focus on more personalised outcomes for service users, it has been necessary to transform current services as the demographic changes will make continued provision of traditional services unsustainable. This has identified a need to focus on more preventive/upstream interventions to make the most effective use of our current and shrinking resources to assist people to lead healthier, fitter and fulfilling lives in their local communities. This has resonated with service users themselves who have higher expectations and want support and services to help them to maximise their independence and wellbeing at home or in a homely setting. Enabling people to live independent lives, with meaning and purpose, within their own community, are a fundamental principle of social justice and an important hallmark of a caring and compassionate society.

This has enabled multi-disciplinary, multi-agency teams to create approaches that focus on the shift from ‘care’ provision to ‘enablement’ and rehabilitation, using the expertise of these professions and of the whole team to work with individuals and carers to best effect.

Enabling and Intermediate Care are core elements of the strategy to reshape our health, care and support services for older people and those with long term conditions. Intermediate care encompasses a range of functions, with focus on prevention, rehabilitation, reablement and recovery depending on the needs of the individual.




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Integrating service redesign and role development and involving alliances between partners providing complementary services will ensure that the potential benefits from connecting and aligning the projects is maximised i.e. the whole is more than some of its parts.

Figure 9. The health care program in West Lothian (Scotland).

West Lothian has now a health care program operational with four main components (see Figure 9). The main aim of the Programme is to avoid hospital admissions and promote, enable and sustain independence and social inclusion for service users and carers. The Programme comprises of the following components

REACT - An alternative to hospital admission for the >75’s

24/7 Crisis Care - To further contribute to avoiding hospital admissions by allowing pople to deal with crisis in their own home.

Reablement Service - Designed to help people learn or re-learn the skills necessary for daily living which may have been lost through deterioration in health and/or increased support needs.

Home Safety Service - Provision of telecare equipment to give increased safety and security for disabled, elderly and vulnerable people in their own homes.

West Lothian has introduced a Telehealthcare Project Team which reports to the Lothian Telehealtcare Board. The Project Team aims to coordinate activities in line with the National Telehealth and Telecare Delivery Plan for Scotland to 2014 and is an active participant in the DALLAS/LivingitUp6 project. Living it Up will provide the user with better connections to information, products, services and the community to help you manage health and wellbeing. These services can be

6 Living it Up is the Scottish element of the UK-wide Dallas project and is funded by a consortium led by the Technology

Strategy Board, the Scottish Government, Highlands and Islands Enterprise and Scottish Enterprise in partnership with other

key stakeholders, including local health boards and local authorities.




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delivered through familiar technology like a TV, mobile phone, games console, computer or tablet. The Scottish system developed and reported the Scottish Patients at Risk of Readmission and Admission (SPARRA-1, 2010) as an individual risk prediction tool of unplanned hospital admissions in the next twelve months, as reported in detail in the main document. SPARRA is being used as a case finding tool. The initial version was based on a source population of about half-million people. Over the last years, SPARRA has been evolving toward a population health scope with progressive emphasis on frailty and long-term care. The current source population encompasses 3.4 million people including both Primary Care and Hospital Datasets. The source datasets are expanding to cover additional target areas. The tool is progressively taking into account the interplay between healthcare and social support. The current version (SPARRA-3) is becoming a comprehensive risk assessment tool, highly flexible and fully owned by the Scottish health authorities. Consequently, it has no constraints due to licenses. The link between the current case-finding tool and clinically applicable health risk assessment constitutes a future goal.




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