An Integrated Primary Care sector: a
view from the front line
Dr Frank R Jones – President RACGP
Bessie
85 years old
30 years of continuous care
18 inter-related complex co-morbidities: 14 medications
ADLs
Number of consults
Number of referrals, pathology, radiology, specialists, allied health
Number of presentations to ED, real and prevented
Number of admissions, real and prevented
Discharge protocol and timing
Communication and teams
Continuity of care
Topsy-Turvy
What?
Integrated care is care that crosses boundaries between primary,
community, allied health and hospital care and extends beyond
health into social care and support too. Providing integrated care is
a goal of health systems around the world and is a way of optimising
the outcomes for patient, provider and system.
According to the WHO, integrated service delivery is ‘the organisation
and management of health services so that people get the care they
need, when they need it, in ways that are user-friendly, achieve the
desired results and provide value for money’.
Digital technology
General practice - hospital interface
Studies demonstrate that improved integration of care result in:
• Reduced hospital presentations
• Reduced hospital admissions
• Reduced hospital stay
• High end of town costs
Patients first
30% presentations in General Practice are acute health issues
70% presentations are now related to chronic health issues: high end
users of our health system
-Team based
-Coordination and systems critical
Digital technology
[up to 1/3 of total presentations do not fit into a recognised medical
model of illness]
Complex co-morbidities
Chronic disease costs 70% of the budget and 70% hospital beds are
for chronic disease
About the RACGP
•
Sets the standards for education and training, including prevocational,
vocational, Fellowship, and continuing professional development
•
Develops clinical resources and support for an integrated practise
•
Sets the standards for general practices
•
Supports and foster primary health care research
•
Advocacy…
The problems 1
Science and technology
Sub-specialisation
Patient expectation
Journalist expertise
Hospitals!
Complexity
[Costs: 46% of FFS Medicare billings spent on 10% of the population]
Rx Primum non nocere
The problems 2
Duplication
Fragmentation
Blame games [politics and geography]
Our funding model
Digital technology
Change for integration to
happen!
The STRUCTURE
[systems]
The CULTURE
[people and professionals]
General practitioners – what we dowhere do we fit?
•
General practice is defined as whole person, patient centred, ongoing
coordinated care
•
The expert generalist : diagnosis: therapeutics: continuity: prevention
•
Provide undifferentiated care
•
Treat the person, not just the disease
•
Our practice is not limited by age, a body part, or a condition
WHO view
“The first physicians were generalists.
Family doctors have always been the backbone of health care
Family doctors have always been the bedrock of comprehensive,
compassionate, and people centred care”
Margaret Chan DG WHO
The efficiency of general practice
• General practice is the most efficient component of the health
system
• Continuity of care with a regular GP not only reduces ED visits, it
also leads to a fall in elective hospital admissions.
• Government costs per person per year for GP (in real $) have
remained relatively steady for 15 years [$23.80 per month]
• Hospital costs per person (in real $) have increased by
approximately 50% over a similar period1
The medical culture
Over diagnosis
Over treatment
Referral pathways
Diagnosis creep
Poly pharmacy: over prescribing
Defensive medicine
“ can’t let go”
Death defying
Watchful waiting
The hospital issue
Real life happens outside hospitals!
Our systems encourages the use of hospital care
A death defying health business
8.2% hospital admissions preventable [572,124 patients]
ED presentations up by 6% annually
18% admissions iatrogenic
35% referrals to hospital may be inappropriate
Why do these patients present?
• Complexity of management of chronic disease, particularly for
patients with multiple needs
• Fragmentation of care – overuse, underuse and misuse of health
resources
• Over diagnosis – patient harm and health system cost
• Medication error and poly-pharmacy
• Lack of patient compliance ? What does this mean?
• Ultimately, mismanaged care of patient because no one is
responsible for coordinating care
• Digital technology
Collusion of anonymity
Collusion truly occurs when
"the patient is passed from one specialist
to another with nobody taking responsibility for the whole person“
(Editorial: The Doctor, his Patient and the Illness - revisited. Balint
Society Journal; 2005. 33http://www.balint.co.uk/journal).
We know
•
Early intervention prevents deterioration and promotes management of
chronic disease
•
The evidence shows that prevention is a cost-effective way of improving
population health3
•
Centralised coordination of patients with complex needs reduces the risk of
an adverse event leading to hospitalisation
•
General practice is centrally placed to deliver preventive and coordinated
health care
•
General practice has unrivalled capacity and population reach, with:
• Over 134 million consultations per year4
• 89% of the Australian population visiting their GP at least once a year4
The business case
•
There is a strong business case for integration to improve the interface
between hospitals and general practice
•
Investment upstream (i.e. primary health care) will result in savings
downstream (i.e. the acute setting)
•
Keep patients in the community for longer, and if admitted to hospital – get
them back into the community sooner
•
Even a modest reduction of 10% in avoidable chronic disease separations
would provide a savings of over $100,000,000 nationally
•
Digital technology
The evidence….
•
•
•
•
An increase of 1 general practitioner per 10,000 population is associated
with a 6% decrease in mortality: conversely a higher ratio of specialists per
population is associated with increased costs and poorer health outcomes
The effective delivery of primary health care services results in a significant
positive impact on health outcomes at a national level6
Australian and international evidence demonstrated that structured,
integrated GP led primary care, reduces:
• Hospital presentation (32 – 40% drop)
• Hospital admission (16 – 24% drop)
• Length of stay (36% drop).7,8,9,10
These are not theoretical figures: real reductions, involving real patients,
and real practitioners
What does integrated care involve?
•
Strengthen the interface between GPs and hospitals – we need to
communicate better: SILOS OF CARE UNNACEPTABLE
•
Support GP-led team care arrangements for patients with complex needs,
which includes:
• Patient handover – genuine GP involvement in admission to hospital
and discharge
• Improved clinical communication between providers, reducing
fragmentation
• Service coordination, including patient reminders, follow-up, and clinical
advice
• Ultimately, we need to support patients with complex needs navigate the
health system, improving health outcomes, managing them better, and
reducing hospital costs
• Digital technology
Hearing but not listening
What do we need to make it happen?
•
Expectation is that general practice and primary health care will manage the
majority of chronic conditions
•
GPs can assume this role – but are not currently supported to facilitate
integrated care
•
It is not possible for GPs to absorb the additional work required without
appropriate support
•
Require programs aimed at promoting and supporting the integration of
care between the community and hospital
•
Programs that support integrated care will save hospital funds at local, state
and national levels
True integration how? 1
Structure
-Follow the patient via the medical home concept: patient enrolment
-Get the digital technology working
-Break down the traditional GP-hospital divide “the head of the bed”
-Locally responsive
-Totally re-evaluate OPD services
-Governance issues
-Flexibility
-Enhance generalist training
-Red tape issues
-Where are the Social services?
True integration how? 2
Culture
-Re evaluate the role of 2o hospitals as community hubs
-Clinical leadership: use consultants as consultants
-Them and us philosophies
-Use GP expertise on admission and discharge
-Referral pathways
-Digital technology
The patient centred medical
home: PCMH
The PCMH is an approach to providing comprehensive care, whereby
each patient has a stable and ongoing relationship with a general
practice that provides continuous and comprehensive care from
infancy to old age
The PCMH facilitates partnerships between individual patients, their
personal GP and extended healthcare team, allowing for better
targeted and effective coordination and integration of clinical
resources to meet patient needs
The concept of continuous care supports the critical and core role of
the GP as the coordinator of patient care
References
1
Australian Government Productivity Commission. Report on Government Services 2013. Canberra: Productivity
Commission, 2013. Available at www.pc.gov.au/gsp/rogs/2013 [Accessed 5 May 2014].
2 Australian Institute of Health & Welfare, Australian Hospital Statistics 2012-13
3 The Department of Health, Annual Medicare Statistics 2013-14
4 Vos T, Carter R, Barendregt J, Mihalopolous C, Veerman L, Magnus A, Cobiac L, Bertram M and Wallace A.
Assessing Cost-Effectiveness in Prevention (ACE-Prevention): Final report. September 2010. University of
Queensland, Brisbane and Deakin University, Melbourne.
5 Starfield B, Leiyu S, Grover A, Macinko J. The Effects of Specialist Supply on Populations' Health: Assessing the
Evidence. Health Affairs 2005: doi: 10.1377/hlthaff.w5.97
6 Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for
Economic Cooperation and Development (OECD) countries, 1970–1998. Health Services Research. 2003;38(3):831–
865
7 Grumbach K and Grundy P. Outcomes of implementing patient centred medical home interventions: A review of the
evidence from prospective studies in the United States. Patient-Centred Primary Care Collaborative. . November 16
2010. Available from: http://www/pcpcc.net
8 GilfillanR, Tomcavage J, Rosenthal M, Davis D, Graham J, and Roy, J. E.Value and the Medical Home: Effects of
Transformed Primary Care. American Journal of Managed Care 2010;16(8):607-614
9 Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA Jr. Community care of North Carolina:
improving care through community health networks. Ann Fam Med 2008;6: 361-367
10 Geisinger Health System. Presentation at White House Roundtable on Advanced Models of Primary Care:August 10,
2009; Washington DC, United States
[food for thought]
Minimise errors in diagnosis
Discontinue low or no value practices
Defer unproven interventions
Select care options as compared to cost
Target clinical interventions to those who will derive greatest benefit
End of life considerations
Actively involve our patients
Minimise day to day operational waste
Convert healthcare institutions into rapidly learning institutions
Integrate patient care across all settings