23rd European Social Services Conference – Lisbon 2015, 6-8 July
Workshop session: Connecting primary care and prevention for
integrated service delivery
Integrated service delivery
in Portuguese primary
health care
António Pereira, André Biscaia, Sílvia Machaqueiro
Research project: Commissioning in Primary Health Care in Portugal:
Research and Practice – A Joint Approach
(“Contratualização em Cuidados de Saúde Primários: Investigação e Prática –
uma abordagem conjunta”, ref. INSA/2011554EXT)
Outline
Why do we need integrated care?
What do we mean by ‘integrated care’?
Integrated service delivery
How to achieve health care integration?
Integration of care in Portugal
Measuring Integrated Care
2
Why do we need integrated
care?
•
One of the responses to current health system challenges
(ageing societies, burden of chronic disease, multimorbidity…)
•
Care patterns with multiple providers
“…a typical patient sees a median of two primary care physicians and
five specialists each year, in addition to accessing diagnostics,
pharmacy, and other services” (Strandberg-Larsen, 2011)
•
Achieving greater efficiency and value from health delivery
systems by:
•
Addressing fragmentation in patient services
•
Providing better coordinated and more continuous care
3
What do we mean by „integrated
care‟?
Organising principle for delivering
health care aiming at:
•
Improvement of patient
experience
•
Achieving greater value from
health delivery systems
•
Addressing fragmentation in
patient services
•
Enabling better coordinated and
more continuous care
Integration involves connecting the health
care system (acute, community and
primary medical) with other service
systems (such as long-term care,
education or housing services) in order to
improve outcomes (clinical, satisfaction,
efficiency).
Concept bringing together inputs, delivery,
management and organization of services
related to diagnosis, treatment, care,
rehabilitation and health promotion.
Means to improve the services in relation to
access, quality, user satisfaction and efficiency.
The Nuffield Trust, 2011; Leutz, 1999; Gröne & Garcia-Barbero, 2001
4
What do we mean by „integrated
care‟?
Different health
and social care
providers coming
together
Planning
Financing
Policy-makers
Leaders
Information systems
Information sharing
The King’s Fund, 2013
Patient needs
at the centre
5
What do we mean by „integrated care‟?
Strandberg-Larsen, 2011
6
Integrated Service Delivery
“The management and delivery of health services so that
patients receive a continuum of preventive and curative
services, according to their needs over time and across
different levels of the health system.”
Poor integration of primary, secondary and tertiary care
lead to inefficiency and lack of quality, creating
unnecessary difficulties for health care users.
OMS 2008; Lopes et al., 2014
7
How to achieve health care
integration?
•
•
•
Development of disease
management programmes
Sharing of activity plans and
budget
Sharing of administrative
procedures
•
Integration of clinical data
•
Implementation of
communication systems
Lopes et al., 2014
•
Case management
•
Creation of cross-disciplinary
teams
•
Training programmes involving
different medical professionals
•
Development of patient referral
systems
8
Integration of care in
Portugal
9
Horizontal integration
Vertical integration
Santana, 2014
10
Santana, 2014
11
Still some barriers to integration of care:
•
Different entry points into the health system
•
Difficult information flow between institutions and
professionals
•
Separation between health and social care
•
Little public provision of community care services in
Portugal (including long-term care)
12
However, some integration
mechanisms are already in place:
•
Clinical guidelines
•
Strengthening of the evaluation and quality culture
•
Development of training and development plans between clinical
leaderships in ACES and hospitals – emphasis on interfaces among levels
of care
•
Implementation of RNCCI (2006) – under two different Ministries + links
with acute care hospitals and health centres
Combines teams providing long-term care, social support and palliative activity within community services,
covering hospitals, local and district social security services, the Solidarity Network and municipalities.
•
Creation of Family Health Units (USF) – primary care
Pisco, 2008
13
PHC Reform 2005
Ministry of Health
ARS – Regional Health
Administrations (x 5)
Hospitals
ACES - Health centre groups x 74 (55)
Board
Executive Director
Executive Council
Clinical Council
Comunity Council
UAG
Functional Units
URAP
UCC x 232
USP x 74
UCSP x 459 USF x 421
Author: André Biscaia
Implementation of USF/FHU (Family
Health Units)
Restructuring of health centres →
Health Centre Groups
• Population: 50.000 to 200.000
• Management structure, shared
resources and tools
• USF – self-organised, multiprofessional care-providing teams
• UCSP – Equivalent to USF but under
the traditional model
• URAP – Shared Resources
(psychologists; nutritionists; social
workers)
• USP – Public Health Services
• UCC – Community Care Unity (run
by nurses)
• UAG - Management support unit
14
Integration of care in Portugal
•
Integrated care processes
•
Joint action plans
Through cooperation between ACES’ and hospitals’ clinical
boards for some types of conditions
15
EXAMPLE OF AN INTEGRATED CARE
PROCESS FOR PATIENTS WITH
VASCULAR RISK
DGS, 2014
16
Integration of care in Portugal
Some tools and mechanisms
Electronic referral system
PHC  hospital (Consulta a
tempo e horas – CTH)
Development of referral
mechanism from a whole-referralcycle perspective: “starting point →
assessment → response → arrival
→ assessment” and conclusion of
the process in PHC.
Health Data Platform
Access to essential available
information:
• Clinical assessment
• Active problems
• Exam results (including imaging,
therapies, risks and specific
alerts)
17
Integration of care in Portugal
Some tools and mechanisms
Portal BI|USF
•
Accountability
•
Sharing
procedures
http://www.biusf.pt/
18
Integration of care in Portugal
Some tools and mechanisms
Portal BI|USF
•
Accountability
•
Sharing
procedures
http://www.biusf.pt/
19
Attempts at integrating care
provision
Organisational models
Patient referral
Secondary care
(hospital)
LOCAL HEALTH UNIT
(ULS)
Secondary care
(hospital)
ACES
ACES
Family
Health
Unit
Public
Health Unit
Personalise
d care Unit
Tertiary care
Family
Health
Unit
Manageme
nt Support
Unit
Community
Care Unit
Source: Machaqueiro & Lapão, 2013
Public
Health Unit
Personalise
d care Unit
Manageme
nt Support
Unit
Community
Care Unit
20
However, evidence shows ULSs haven‟t
integration and performance expectations
met
21
Source: Jornal Público
However, evidence shows ULSs haven‟t
integration and performance expectations
met
22
Source: Jornal Público
Source: Jornal de Negócios
However, evidence shows ULSs haven‟t
integration and performance expectations
met
ERS, 2015
23
Source: Jornal Público
Source: Jornal de Negócios
Positive steps taken towards integrated
care in Portugal
• Integration of clinical data
• Implementation of
communication systems
• Case management
• Creation of cross-disciplinary
teams
• Training programmes involving
different medical professionals
• Development of patient referral
systems
OECD, 2015
24
Challenges to integrated care
OECD, 2015
25
Measuring integrated care
PIRU, 2014
26
Measuring integrated care
Singer, 2011
27
23rd European Social Services Conference – Lisbon 2015, 6-8 July
Workshop session: Connecting primary care and prevention for
integrated service delivery
Thank you
António Pereira, André Biscaia, Sílvia Machaqueiro
Research project: Commissioning in Primary Health Care in Portugal:
Research and Practice – A Joint Approach
(“Contratualização em Cuidados de Saúde Primários: Investigação e Prática –
uma abordagem conjunta”, ref. INSA/2011554EXT)
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