CASE STUDY: COLLABORATION TOWARDS BETTER HEALTH OUTCOMES FOR HIGH-RISK PATIENTS

Hendrik Hanekom: Chief Executive , Intercare GroupPaul Hendey: Executive, Healthbridge

The Innovation Imperative

Harvard Business Review – Michael E Porter and Thomas H Lee – October 2013

“Providers that cling to today’s broken system will become dinosaurs. Reputations that are based on perception, not actual outcomes, will fade.

Those organizations that can master the value agenda will be rewarded with financial viability and the only kind of reputation that should matter in health care - excellence in outcomes and pride in the value they deliver.”

THE AGENDA

1. Current realities

2. Solution

3. Case studies

4. Why collaboration?

5. Patient engagement

6. An enabling system

7. Trends worth noting

8. Emerging next steps

Health Profile Segmentation

2%

8%

20%

70%

The sickest patients:

Cost the most

Are the most exposed and vulnerable to system

fragmentation

Further increasing cost and reducing quality of care

Complex disease- Multi-morbidity with unstable conditions

Significant chronic illness- 1 or more chronic conditions

Well but at risk- Lifestyle related or- Significant acute health event

Healthy- Minor health events only

21%

27%

52%

% SPEND

Source: DHMS

Cost of Healthcare5 year average annualised inflation rates (2010-2014)

Source: Discovery Health

Demand and Supply-side Cost Drivers

Aging populations

Growing burden of disease and cost of

healthcareDemand Supply

Lack of preventative medicine and screening

Unhealthy lifestyles are driving chronic

disease

Incentive systems reward volume, not value

Care fragmentation

Technological developments focus on

enhancement, not value

Patients seek more“Maximal care is optimal

care”

Adverse selection

Demand and Supply-side Cost Containment

Growing burden of disease and cost of

healthcareDemand Supply?

Screening and wellness programmes

Formularies

DSP’s

PMB’s

Case management

Scheme based CDM

Fragmentation is a Cost Driver

PATIENTSCHEMES

SPECIALISTGP SUB-ACUTEPATH/RADACUTE

HOSPITAL

We are getting our lines crossed

Little communication / collaboration between provider types

No joint communication / collaboration (schemes and provider)

Chronic and complex patients most vulnerable to effects of fragmentation.

What is the Solution?

At its core is

maximizing value for patients

It is time for a fundamentally new

strategy!!

How to Become a Value-based Organisation

SCHEME

Source: Harvard Business Review – Michael E Porter and Thomas H Lee – October 2013

Transformation must come from

within

Value is determined by

how medicine is practiced

Doctors and provider

organizations are ultimately

responsible

Patients, health plans, employers

and system providers can

hasten transformation

Value Enhancers

SCHEME

Treating subgroups of patients with similar needs

Team based services

Measured outcomes

Value improvement

should be rewarded

Primary care should be integrated

with specialty providers

Source: Harvard Business Review – Michael E Porter and Thomas H Lee – October 2013

Case Study: High Risk Patients in Sub-acute Hospitals

SUB-ACUTE

ACUTE

HO

SPITAL

PATHOLOGY

RADIOLO

GYAL

LIED

HCP

s

Structuring the Coordination of Sub-acute Care

PROGRAMME STRUCTURE

Acute Hospitals Existing Member Base Practitioner referral

CARE SERVICES

Primary Care Provider Multi-disciplinary team Facility Based Care Home Based Care Telephonic Support Services

PATIENT RECRUITMENT

4000Enrollees

5Regions

12Care

Coordinators

15Facilities

450Doctors

consented

40Doctors trained in geriatric care

coordination

1 Scheme

Coordination of Sub-acute Care – The Results

IMPROVED QUALITY LOWER MEMBER COST EXPERIENCE

Source: Discovery Health

Case Study: High Risk Patients in the Ambulatory Setting

Structuring the Coordination of Primary Care

PROGRAMME STRUCTURE

Existing Member Base Practitioner referral Enrolment

CARE SERVICES

Primary Care Providers General practitioner Health Coach

Multi-disciplinary team Facility Based Care Telephonic Support Services

PATIENT RECRUITMENT

1 Scheme

225/450Enrollees

1Region

5Health coaches

5Facilities

40Doctors

Coordination of Primary Care – Assessment Criteria

PROCESS MEASURES CONTROL MEASURES OUTCOME MEASURES EXPERIENCE MEASURES

Consultations Hba1c Blood pressure Lipogram PEFR

Level of metrics vs best practice guidelines

Reduction in:

Preventable hospital admissions

Unnecessary out of hospital specialist consultations

Unnecessary casualty visits

Patient experience related to:

Waiting times Ease of appointment Staff attitude Doctor

communication

Coordination of Primary Care – The ResultsENROLMENT (1 year)

Intercare International evidence

50% 7-30%

RETENTION (1 year)Intercare International evidence1

93% 29-%

PARTICIPATION (1 year)Intercare International evidence 2, 3

80% 20-75%

1Documenting participation in employer-sponsored disease management program: selection, exclusion, attrition, and active engagement as possible metrics2 Institute of Health Care Knowledge: Research Summary. Helping people help themselves: driving participation in health improvement programs3Health and wellness programs in the workplace. Fact sheet. http://www.bc.edu/research/agingandwork/ 4The Impact of a Proactive Chronic Care Management Program on Hospital Admission Rates in a German Health Insurance Society5Long-term impact of a chronic disease management program on hospital utilization and cost in an Australian population with heart disease or diabetes6North Carolina Medicaid Childhood Asthma Program

HOSPITAL ADMISSIONS

Intercare International evidence

Preliminary data demonstrates encouraging results, but patient numbers and duration to be increased

6.2-34% 4, 5, 6

CASUALTY VISITS

Intercare International evidence

Preliminary data demonstrates encouraging results, but patient numbers and duration to be increased

8% 6

Realities of Disease Management Programmes

Segmentation

1000 patients

Contacting

500-750 patients

Enrolment

250-375 patients

Retention Participation

125-200 patients

Change

60-100 patients

Source: Leveraging the Trusted Clinician: Documenting Disease Management Program Enrolment

Key learnings in Disease Management

Segmentation Contacting Activation Delivery

1American Healthways data2Leveraging the Trusted Clinician: Increasing Retention in Disease Management through Integrated Program Delivery3 Leveraging the Trusted Clinician: Documenting Disease Management Program Enrolment

International literature

Enrolment vs Engagement 7-30% provider driven1

95% funder driven1

Selection bias, barrier of inertia and denial1

Primary care physician involvement2

Administration RetentionParticipation

Intercare’s learning's

Segmentation Scheme and provider important

Enrolment Provider adds great value

Who consents GP vs nurse

Concerns at activation Who will pay?

Retention Claims and scheme involvement Over-treatmentParticipation Integrated DM model Collaboration

Coordination and Collaboration is part of the Solution

Direction of information and relationships is crucial:

PATIENT

PHC TEAM

SPECIALIST

SUB-ACUTE

ACUTE

HO

SPITAL

PATHOLOGYRADIO

LOGY

ALLI

ED H

CPs 1. Circular between

provider types via IT platform

2. Inward via the IT platform and PHC team

INFORMATION TECHNOLOGY

Does Coordination equal Collaboration? Collaboration means more than coordination It suggests an element of trust, common goals and a

commitment to work together and put the patient first

Collaboration needs to be on multiple levels and is somewhat dependent on the programme phase:

Programme phase Collaborative parties

Planning Provider-scheme

Segmentation Provider-scheme

Contacting and enrolment Provider-schemePatient-schemeProvider-patient

Delivery (focusing on retention, participation and change)

Provider-schemePatient-schemeProvider-patientProvider - provider

AN ENABLING SYSTEM IS NEEDED

FOR ALL PHASES FACILITATING CO-ORDINATION AND COLLABORATION

What does an enabling system look like, to support a DMP?

Some important considerations that have shaped our approach …

#patient_engagement ... we have much to learn

“This is serious”

“Many people live very normal lives with this chronic

condition”

“You need to decide to take

responsibility for YOUR health”

“We will help you on YOUR journey”

A patient diagnosed with a chronic condition needs to hear and internalise a few things:

Change behaviour – “Fogg’s” Model

Dr. BJ Fogg founded the Persuasive Tech Lab at Stanford University

DMPs are deceptively complex

So how can we achieve both…

Patient engagement Make it simple

an enabling patient engagement system

1. Bring patient

into the practice

2. Provide Dr with patients latest

health summary

3. Record only

relevant patient metrics

4. Track progress -

reward

trends we are seeing - patient engagement

PRG 1 ( 430 Patients )running for 24m

PRG 2 ( 193 Patients )running for 12m

PRG 4 ( 11 Patients )running 3m

0%10%20%30%40%50%60%70%80%90%

100%

Enrolled Engaged Participating DMP adherence

emerging next steps

0 1 2 3 4 50

50

100

150

200

250

PRG1 & 2 - HbA1c tests performed

Number of HbA1c tests performed

Num

ber

of p

atien

ts (

Tota

l 512

)

THANK YOU