The Bellagio Model
“Bellagio Model on Population-oriented Primary Care”
- Key features –
1. Shared leadership – developing partnership in leadership between public
health experts and medical professional associations
2. Public trust – reliability of and trust in policy makers and governance
structures based on accountability and transparency, as well as in
providers to deliver high-quality, efficient care
3. Population-oriented management across the care continuum, following
up on healthy and diseased people
4. Vertical and horizontal integration – integration with health and social
professionals in the local community such as social workers, community
nurses, physiotherapists, dieticians, etc. (horizontal) and collaboration
between primary care providers and the hospital system/specialists
(vertical)
5. Networking of professionals – supporting community-based
interdisciplinary networks for population-oriented care
6. Infrastructure – application of evidence-based guidelines in clinical care;
information technology across all care settings; care management by
medical professionals other than doctors; integrated and coordinated
disease management programs; self-management support for patients
7. Payment mix – capitation fee with additional incentives that are “best for
patients”
8. Standardized measurement – systematic generation and evaluation of
data for the development of indicators for benchmarking in health care and
for care management
9. Active program for practice change – structuring change management
in health care at different levels (i.e. medical education, professional
development); formulation of goals, actions, measurement and evaluation
tools (plan/do/study/act)
The Bellagio Primary Care Group, Lago di Como/Italy, 6 April 2008
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Genesis
A group of 24 distinguished experts from Europe and the US came together at
the The Rockefeller Foundation Bellagio Study and Conference Center, Italy,
from April 2 to 6, 2008.
Under the conference title “Improving primary care in Europe and the US:
Towards patient-centered, proactive and coordinated systems of care”
practitioners, researchers and policy advisers together discussed and designed
The Bellagio Model, a comprehensive reference framework for accessible,
continuous, comprehensive, population-oriented primary care for the 21st
century that ensures coordination with other care when needed. Because of
these features, the Bellagio Model is particularly apt to cope with the needs of
the chronically ill. It is well suited to support and activate patients, and to
overcome the divide between doctors, professions, care cultures, and
institutions.
In Bellagio, conference participants – all experts in primary care, chronic care
research, and public health - convened and agreed to formally constitute the
Bellagio Primary Care Group.
Need for health system improvement and change
Participants agreed that health systems must become more pro-active, helping
individuals to stay healthy and avoid the development of (additional) chronic
conditions. Primary care as first contact care, accessible by all, guaranteeing a
sustained and trustworthy partnership between providers and patients,
comprehensive, coordinated care for a predetermined population, activated by
patient choice plays an essential role in improving health care systems
altogether.
System changes endorsed by politics in some countries do in fact support
these developments: Participants looked back at more than ten years of
experience in implementing new approaches in primary care from Europe and
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the U.S. that take into account the special needs of individuals with chronic
conditions, and assessed the various strategies for improvement.
Expertise and experience from nine countries
They examined different approaches and strategies from eight countries (UK,
DK, Spain (Catalonia), USA, D, F, P, NL) based on country case studies that
were prepared by participants prior to the conference.
One of the models they looked at more in depth was the Chronic Care Model,
(CCM) an evidence-based, conceptual framework that served as a key
reference for developing the Bellagio model. Widely used in the US and
adopted in several European countries the CCM describes changes to the
organization and delivery of care at the practice level that help to improve
outcomes among patients with chronic conditions.
Aside the model, participants analysed technical and managerial input from
health services research – issues critical for primary care and health care
improvement overall.
The model: A comprehensive and integrative framework
As a result, participants identified and defined nine key features
(“ingredients”) of a consistent and comprehensive care model, listed above.
Put together and put in practice, all of these features constitute the “Bellagio
Model on Population-oriented Primary Care”.
1. Shared leadership – developing partnership in leadership between public
health experts and medical professional associations. Establishment of
umbrella organizations that can strategically guide redesign of (primary)
health care systems.
2. Public trust – reliability of and trust in policy makers and governance
structures as well as in providers to deliver high- quality, efficient care.
Trust can be developed by increasing accountability and transparency
through eg. the establishment of quality indicators, benchmarks, etc. Public
trust can also be influenced by people's experiences in contacts with
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representatives of institutions, in its turn influencing how people enter
these contacts. Moreover, trust can be influenced by underlying cultural
values and norms, and by the actual health care situation (van der Schee
et al., 2003).
3. Population-oriented management across the care continuum, following
up on healthy and diseased people.
4. Vertical and horizontal integration – integration of primary and
secondary care, of health care in the community and in other public
services. Horizontal integration here means stronger cooperation between
medical and social professionals in the local community (such as social
workers, community nurses, physiotherapists, dieticians, etc.) (Olesen).
Managers/leaders at the same organizational levels in collaborating
organizations (hospitals, communities, general practice) meet regularly to
agree on eg. common goals for the care of patients with certain conditions,
on common use of certain performance measurement tools, or on sharing
of patients between organizations, (risk stratification), and to exchange
important information in general (Frølich). Vertical integration is defined by
better collaboration between primary care providers and the hospital
system/specialists (Olesen). Leaders at the different levels communicate on
important issues and share information in both directions.
5. Networking of professionals – supporting community-based
interdisciplinary networks for population-oriented care. One example of
networking are the knowledge sharing meetings in Denmark. Health
professionals from the hospital and from the health center, including
nurses, physiotherapists, dieticians, physicians, and behavioral therapists
that work directly with the patients, meet on a regular basis. The aim of
the meetings is to ensure a common understanding of care between
organizations and to get different organizational cultures come to a better
understanding and thereby at some time approach a common health
professional culture between organizations. The meetings are lead by the
manager of the local health center and the specialist from the hospital. The
meetings are informal, planned and follow an outline for the meeting
(Frølich).
6. Infrastructure – application of evidence-based guidelines in clinical care;
information technology across all care settings; multidisciplinary care
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teams and care management by medical professionals other than doctors;
integrated and coordinated disease management programs; selfmanagement support for patients.
7. Payment mix – capitation fee with additional incentives that are “best for
patients”.
8. Standardized measurement – systematic generation and evaluation of
data for the development of indicators for benchmarking in health care and
for care management.
9. Active program for practice change – structuring change management
in health care at different levels (i.e. medical education, professional
development); formulation of goals, actions, measurement and evaluation
tools (plan/do/study/act).
A system view: governance, management, and practice
Participants agreed that for the Bellagio Model to work, it will be essential that
all nine key features will need to be put in place in the long run; efforts for
implementation will have to be geared around that comprehensive approach.
By contrast, singling out selected features can only be a first step, as all of
these features do work together and interact in a synergistic, reinforcing
fashion.
The added value of the Bellagio Model compared to existing chronic care
concepts thus stems from its comprehensive vision and from the systemic
approach it takes: It deliberately combines commitment and action at
governance (macro), management (meso) and practice (micro) levels, and it
perceives primary care as a key function to better serve the needs of the
chronically ill, embedded within a broader integrated care delivery scheme.
Bellagio participants also agreed that with primary care at the center and as a
hub, coordination between primary and secondary care will improve: with a
better alignment of treatment objectives and of incentives the frequent
disconnection between the two levels will become less common over time. In
this sense, the Bellagio model wants to make a strategic contribution to
overcoming the inefficient and “unhealthy competition” between professional
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groups and specialities in the delivery of patient-centered health and social
care.
From Bellagio to practice: Making things work
The Bellagio Primary Care Group agreed to
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serve as an interdisciplinary Euro-US network of experts to support
national and international projects on research and policy advice.
-
facilitate the exchange of knowledge and expertise among peers by way
of disseminating and transferring innovative strategies of improvement
into national and international policy and action, and identifying future
topics for analysis and research in chronic care delivery in Europe and in
the US.
-
run a web site, to be hosted by the Bertelsmann Stiftung, aimed to
allow public access and discussion, and to disseminate results more
widely.
-
submit a strategy paper on the Bellagio Model to the British Medical
Journal (BMJ).
-
submit the Bellagio country studies to another public health research
and policy advice journal (International Journal of Integrated Care)
-
present the Bellagio Model at international fora such as WONCA Europe,
EHMA, European Forum of Primary Care, BMJ International Forum 2009,
and various national primary care conferences.
-
disseminate the Bellagio Model via national think tanks, policy advisory
committees and boards.
-
meet again in Berlin in 2010. This meeting will probably be hosted and
sponsored by the Bertelsmann Stiftung.
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