- Uncoordinated care can affect the quality and efficiency of health care, access to care, participation in and satisfaction with care, and health outcomes for chronically ill patients. However, there is a paucity of data in Norway that provide a basis for estimating the size of the problem or clarifying the underlying reasons for inadequate coordination.
- The impact of many changes in delivery, financial and governance arrangements that could be made to improve the coordination of care for people with chronic conditions is uncertain; evaluation is critical when such changes are made.
- Components of the Chronic Care Model and disease management programs, alone or in combination, can improve quality of care, clinical outcomes and health care resource use, but the effects are not consistent and a number of obstacles may hinder their use.
- The impacts of delivery arrangements that have been shown to be effective (e.g. patient education and motivational counselling, provider education, feedback, reminders, and multidisciplinary team work) are generally modest, but important. There is uncertainty about the impacts of other arrangements (e.g. care pathways, case management, and shared care).
- Targeted financial incentives with the aim of achieving specific changes in how care is delivered probably influence discrete individual behaviours in the short run, but are less likely to influence sustained changes, and they can have unintended effects, including motivating unintended behaviours, distortions, gaming, cream skimming or cherry-picking, and bureaucratisation. Therefore, they require careful design and monitoring.
- Similarly, changes in the basic payment methods that are used for both clinicians and institutions in order to offset the inherent limitations of each require careful design and monitoring. A long-term perspective with continual adjustments is more likely to be successful, than dramatic one-off changes.
- There is not evidence to support any one governance model as being better than others. However, specific structures are likely needed at different levels to improve coordination:
- Clinical governance (healthcare professionals' accountability for quality of care) for both primary and secondary care
- Boards at the local level that conduct detailed oversight and monitoring for both primary and secondary care
- A regional board that coordinates different local networks in the region
- A central governance structure that sets broad standards, which the regional and local boards are responsible to adhere to and implement
- Consumer and stakeholder involvement in governance arrangements at all levels is a strategy for achieving better coordination of care and other health goals, as well as a goal in itself, but there is little evidence of how to best to achieve this.
- Because there are multiple barriers to organisational and professional change, simple approaches to implementing change are unlikely to be effective, change is likely to occur incrementally and to require ongoing attention.
As part of the development of the Integrated Health Care Reform, this
report was prepared to inform deliberations among policymakers and stakeholders regarding how best to reform the Norwegian healthcare system to improve the coordination or integration of health care for people with chronic conditions.
The policy issue
The aim of the Integrated Health Care Reform is to improve the health services through better coordination across different levels of care and from different providers within each level. In this policy brief, we focus specifically on coordination of care for patients with chronic diseases, although the goals of the Integrated Health Care Reform and the problem that it will address have not yet been clarified. The focus is on chronically ill patients because of the importance of chronic diseases in terms of burden of disease and healthcare costs and because coordination of care for chronic diseases is, to some extent, illustrative of challenges facing the whole system.
Possible reasons for problems with the coordination of care in Norway include separation of hospital (specialist) and community (primary) care with different administrative and financial structures and different cultures that may inhibit collaboration; financial disincentives that inhibit collaboration; inadequate implementation of the ‘regular GP’ reform as well as consequences of that reform; consequences of a centralisation process that occurred as part of the hospital reform; inadequate implementation of the Patients’ Rights Law (which, among other things, gives patients who need long-term care and coordinated services the right to an individual plan), as well as other regulations; barriers to good communication; and a lack of leadership and a common culture that promotes collaboration.
Integration or coordination has been pursued in many ways in different health systems and many overlapping terms are used to describe these. A systematic review of care coordination found more than 40 distinct definitions comprised of five key elements:
- Integration of care activities has the goal of facilitating appropriate delivery of healthcare services.
- Numerous participants are typically involved in care coordination.
- Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient’s care.
- In order to carry out these activities in a coordinated way, each participant needs adequate knowledge about their own and others’ roles, and available resources.
- In order to manage all required patient care activities, participants rely on exchange of information.
The Chronic Care Model is probably the best known and most widely used framework for conceptualising the delivery of care to people with chronic conditions. It was developed as a framework to guide system changes and quality improvement and includes a number of components. Components of the Chronic Care Model and various other disease management programs, alone or in combination, can improve quality of care, clinical outcomes and health care resource use, but the effects are not consistent and numerous obstacles hinder their use. It is very uncertain whether all components of the Chronic Care Model, or any other model for chronic care, are essential for improving chronic care.
Components of broad frameworks or service delivery models that have been shown to be effective generally have modest effects, including patient education and motivational counselling, provider education, feedback, reminders, multidisciplinary team work, some interventions targeted at patients discharged from hospital or the emergency department to home, complex interventions to improve physical function and maintain independent living in elderly people, rehabilitation services targeted towards stroke patients living at home, computerised central recall, with prompting for patients and their family doctors, community mental health teams, collaborative care for depressed patients in primary care, and intensive case management for patients with severe mental illness.
The effectiveness of many other components is very uncertain, including evidence-based care pathways, case management, shared care, home visiting programs for older people with poor health, and most information and communication technologies.
Financial arrangements have important implications for the coordination, quality and costs of care.
The benefits and costs of using financial incentives to improve coordination or quality of care are uncertain. In addition, there is a danger of perverse effects with all types of financial incentives. These include distortions (causing recipients to ignore other important tasks), gaming (changes in reporting rather than desired changes in practice), cream skimming or cherry-picking (selecting patients for whom good outcomes are easy to achieve and avoiding those from whom good outcomes are difficult to achieve), dependency on financial incentives (if provider behaviours are not ingrained, they may disappear when the incentives end or new incentives are introduced), and bureaucratisation (pay-for-performance schemes may have substantial administrative costs associated with monitoring performance and managing disbursement of the financial incentives).
Different methods of paying clinicians (fee-for-service, capitation, and salary) also all have perverse incentives for patient care as well as potential advantages. The impacts of different payment systems in practice are very uncertain. Similarly, different payment methods for institutions (fee-for-service, capitation, per diem payments, case fees and budgets) all have perverse incentives as well as advantages. Their impacts are also uncertain, although there are theoretical reasons for anticipating certain effects, such as increased productivity with ‘prospective’ systems like diagnosis-related group (DRG) payment systems.
Although there is not an empirical basis for advocating a specific governance model for an integrated healthcare system, a governance arrangement that is suitable for integrated health care is likely to require:
- Boards (which currently do not exist in Norway) at the local level that conduct detailed oversight and monitoring of the operations of the component parts of the system for both primary and secondary care;
- A single board at the regional level that coordinates the different networks in the region, oversees and evaluates their performance, and verifies that accepted standards are met across both primary and secondary care; and
- A central governance structure that sets broad standards such as funding and capitation policies, quality indicators or entitlement principles (rights to guaranteed benefits) that serve the interests of the society as a whole while preserving the autonomy of local governance structures.
The term clinical governance has been used to capture the range of activities required to improve the quality of health services. Central among these are the need for all healthcare organisations to develop processes for continuously monitoring and improving the quality of health care and to develop systems of accountability for the quality of care that they provide. There is a need for effective clinical governance within and across different levels of the healthcare system. Fragmentation of the healthcare system inhibits effective clinical governance, particularly in primary care. GPs are traditionally independent and primary care services often are fragmented across multiple providers, with no clear managerial or professional hierarchy through which to implement clinical governance. Evaluations of alternative governance arrangements to address these challenges have not been reported in the scientific literature.
There are a number of barriers to coordinating or integrating care, even in relatively conducive health systems. Because of the many barriers to organisational and professional change, no single approach or intervention is likely to bring about desired changes in the coordination of care. Even with major reforms, changes in behaviour are likely to occur incrementally and to require ongoing attention.
Most interventions used to change professional practice, such as educational meetings, audit and feedback, and outreach visits, achieve small to moderate (but important) improvements in performance. All of these interventions require resources and many require that clinicians have time and space to review their practices and to introduce new ways of delivering services that are more coordinated and effective. Although there is little evaluation of coordinated quality improvement systems, key components are likely to include strategies for effective stakeholder involvement, systematic and transparent approaches to setting priorities for improvements, evidence-based clinical guidelines, efficient methods for accessing data that can be used to assess the quality of care, methods for identifying problems with the quality of care and selecting appropriate interventions to address those problems, and efficient ways of monitoring and evaluating change.
There are many potentially useful tools for implementing organisational changes, but there is almost no evidence of their effectiveness. These include analytic models, tools for assessing why change is needed, such as SWOT analysis, tools for determining who and what can change, and tools for making changes, such as organisational development and project management. Similarly, although it is widely believed that leadership and organisational culture are important for achieving desired changes, there is a lack of empirical research or critical assessments of the role of leaders in health care and it is very uncertain whether efforts to change organisational culture can achieve improvements in performance. It has been shown that the use of clinicians who are local opinion leaders can successfully improve practice, but the feasibility of widespread use of opinion leaders is uncertain.
It may be helpful to consider three broad categories of reform: “linkage”, which would operate through existing structures; “coordination”, which would operate mainly through existing structures, but is a more structured approach that would involve additional explicit structures and processes; and “integration”, which would create a single system with responsibility for all services, resources and funding in a single managed structure. Each of these has potential advantages and disadvantages. There is little evidence to guide a choice between these different approaches. However, an open discussion of the potential advantages and disadvantages of each, informed by the available evidence, and based on a shared understanding of the goals and values that will guide the reform, could help to decide what package of delivery, financial and governance arrangements and which approach is best suited to address the problems faced by the Norwegian healthcare system and achieve agreed upon goals.