Bellagio Conferences
Final Report
The Rockefeller Foundation Bellagio Study and Conference Center, Italy
April 2 to 6, 2008 (Principal Organizers: Gensichen, Schlette and Wagner)
1.
Indicate the title of your meeting.
“Improving primary care in Europe and the US: Towards patient-centered, proactive and
coordinated systems of care”
2.
Provide a brief summary of your conference proceedings, highlighting the key
points and insights you think would be of interest to the Foundation. Please also indicate
the conference outcomes.
Despite clinical differences across all chronic conditions, each illness confronts patients
and their families with a wide spectrum of needs: altering their behaviour; coping with the
social and emotional impacts of symptoms, disabilities, and the threat of death; complying
with a drug regime / taking medicines; and interacting with medical care providers over
time. In return, the health and social care system and its providers must ensure that
patients receive the best treatment regimes to keep disease progression at bay and
mitigate symptoms, as well as to provide information and support to self-manage health,
illness and, ultimately, end of life. Moreover, health systems must become more proactive, helping individuals to stay healthy and avoid the development of (additional)
chronic conditions. Primary care as first contact care, accessible by all, comprehensive,
coordinated care for a predetermined population, activated by patient choice plays an
essential role in improving the systems.
System changes endorsed by politics in some countries do in fact support these
developments: We looked back at more than ten years of experience in implementing
chronic illness care approaches in European and US primary care systems and assessed
the various strategies for improvement.
The conference was the kick-off meeting for the development of a comprehensive
reference framework for population-oriented chronic illness care in primary care: The
Bellagio Model.
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Participants –practitioners, researchers, policy advisors – were experts in primary care,
chronic care research, and public health from Europe and the US. In Bellagio, they
convened and agree to formally constitute the Bellagio Primary Care Group.
We examined different approaches and strategies from nine 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 we looked at more in depth is the Chronic Care Model, (CCM) an
evidence-based, conceptual framework that served as a key reference for developing the
Bellagio model. Introducing a comprehensive approach for chronic illness care in Europe
and already widely used in the US 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. The ultimate aim of the Chronic Care Model is to have informed,
activated patients and prepared, proactive practice teams whose interactions become
more productive and satisfying around chronic illness.
In workshops and round table discussions participants analysed specific technical input
from health services research that had been identified as critical: Pay-for-performance,
practice-based commissioning, integration of primary and community care, continuous
care in chronic conditions, improvement of cooperation between sectors, measurement of
provider support for chronic illness care, indicators for structured chronic care, electronic
health records and standards for data transfer, differences/commonalities between
chronic care and primary care, skill mix in primary care, the advanced medical home.
Plenary sessions were used to build consent on essential elements for strengthening
population-orientated chronic illness care in primary care geared toward the needs of the
chronically ill.
Participants agreed upon the following key features (“ingredients”) for the “Bellagio Model
on Population-orientated Chronic Illness Care”:
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 highquality, efficient care.
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3. Population-oriented management across the care continuum, following up on
healthy and diseased people
4. Vertical and horizontal integration – of primary and secondary care, of health care
in the community and in other public services (i.e. social services, long-term care)
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; 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)
The participants will target future activities and research at these essential elements. They
will refine the Bellagio Model to become a framework of reference for implementing a
sustainable and population-orientated system of chronic illness care in primary care that is
applicable to different health care systems.
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, and efforts for implementation have to
be geared around that comprehensive approach. 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 superiority of the Bellagio Model compared to previous primary
care concepts thus stems for 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 in order to improve
care coordination with primary care at its center and as a hub, the distinction between
primary and secondary care will become obsolete with time. In this sense, the Bellagio
model will ideally make a strategic contribution to overcoming the inefficient and
“unhealthy competition” between professional groups and specialities in the delivery of
patient-centered health and social care.
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3.
Please attach copies of position or discussion papers, if any. (Papers will only be
shared with relevant Foundation officers.)
There is a document in progress, which we are happy to share with the Foundation once it
is finalized.
4.
Indicate the next steps for your group and/or project.
The Bellagio Primary Care Group will
-
finalize the Bellagio Model by mid-June, elaborating in more detail a glossary
around its key features as outlined above under 2.
-
use the “The Bellagio Model on Population-oriented Chronic Illness Care” to refine
the country case studies that assess current status, challenges, and success
factors in chronic illness care in the different countries by mid-August
-
meet eventually every other year to evaluate and review the current developments
in the field.
-
serve as network of experts to support national and international projects on
research and policy advice.
-
network to exchange 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.
5.
Indicate the anticipated publication and distribution of proceedings or
recommendations (if appropriate). Include publisher and approximate date available as
well as name and address of the person to contact for a copy.
-
The Bellagio Primary Care Group agreed to run a web site, to be hosted by the
Bertelsmann Stiftung, aimed to allow public access and discussion, and to
disseminate our results more widely.
-
The Bertelsmann Stiftung will publish conference proceedings, i.e. the country
studies, the technical briefs and an article presenting “The Bellagio Model on
Population-oriented Chronic Illness Care” (s. above 4).
-
The Bellagio country studies will be submitted to a public health research and
policy advice journal: “International Journal of Integrated Care”.
-
The group will further submit a strategy paper on the Bellagio Model to the British
Medical Journal (BMJ).
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The group will 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.
-
The group will disseminate the Bellagio Model via national think tanks, policy
advisory committees and boards.
6. Review the attached list of participants and make changes, if any.
No changes
7.
Please let us know if any connections for funding or implementing the project
occurred from having your meeting at Bellagio.
The Bellagio Primary Care Group will meet again in Berlin in 2010. This meeting will
probably be hosted and sponsored by the Bertelsmann Stiftung, Gütersloh.
8.
Suggestions for how we could improve the Bellagio program, the Center’s facilities
and/or the application process are always welcome.
Many thanks for your excellent support. Thanks to Nadia Gilardoni, our stay was prepared
and orchestrated in the best possible way: smoothly, efficiently, and very, very friendly.
Facilities were superb and conducive to creative and critical thinking. We very much hope
to be able to arrange one of our follow-up meetings again at your fabulous conference and
study center.
Frankfurt/Germany, June 4th, 2008
_______________________
Jochen Gensichen
Institute for General Practice,
Johann Wolfgang Goethe
University, Frankfurt, Germany
______________________
Sophia Schlette
Bertelsmann Foundation,
Guetersloh, Germany
_______________________
Ed Wagner
Center for Health Studies, Group
Health Cooperative, Seattle, USA
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