A case of integration in Baix Empordà (Catalonia), 20 years on the road

摘要

Background : Catalonia healthcare system sat up a process of diversification of providers of services as a result of the publication of the healthcare management act (Llei d’Ordenació Sanitària de Catalunya, 1990). Around 20% of the primary care attention, the greater part of the specialized ambulatory care and hospitals and the almost whole of the residential long-term care had been managed by providers different to the public manager (ICS), although all of them receive public funding. Some of these providers of services moved away from forms of organization, which were fragmented by lines or levels towards systems that integrate all types of care within the same organization. Every organization made this process on their way. In the year 2002 the Health Department of the Government of Catalonia improved this initiative by means of the set up of a pilot proof for the implantation of a model of per capita payment system. Description of practice change implemented and aim : Serveis de Salut Integrats del Baix Empordà (SSIBE), an integrated healthcare management organization (HMO) responsible for providing public healthcare services of some 130,000.000 people at Baix Empordà county, including primary care, specialized care, acute hospitalizations and long-term residential care, adhered to these initiatives and had developed during the last 20 years an intense process of integration patient centred. Along 20 years SSIBE have developed diverse strategies of implementation of changes standing out: creation of an unique information system centred in the patient (includes clinical, administrative and economic information) that facilitates analysis of burden of disease and cost based in individual data; unification of the clinical direction by areas with only and common aims without differentiating levels of attention; implantation of guides of clinical practice identifying the responsibility of the different actors involved (primary care, specialist care, emergency department physicians, rehabilitation, …); common politics of human resources and utilization of incentives for the achievement of clinical aims and of management. The aim of this work is to show the results obtained in this process analysing the organizational changes developed, the instruments used and a series of performance indicators to valuate the model. We compare performance of SSIBE through some benchmarking indicators elaborated by CatSalut (Catalonian healthcare contracting and payment authority) and Atlas of Variations in Medical Practice in the National Health System (a nationwide Health Services Research (HSR) Program concerning the analysis of unwarranted variations in medical practice and healthcare outcomes in Spain). We also use PLAENSA? Satisfaction Surveys results, a tool for assessment and improvement proposals addressed to the insurance services provided by contracted public entities. Key Findings : Some performance indicators like primary care visits, specialized ambulatory care visits, number of urgent hospitalizations and days of hospitalization are about 10% lower than Catalonia as a whole after adjusting by age, sex and comorbidity. In 2014 the hospitalization rate for determinate chronic pathologies in the Hospital of Palamós is of 405.7/100,000 hab in front of 625.5/100,000 for the group of Catalonia. For the potentially avoidable hospitalizations the rate is of 645.6/100,000 persons in front of 980.1/100,000 persons. The percentage of readmissions within 180 days of discharge for determinate selected pathologies is 13.46% in front 17.65% and the one of readmissions for chronic pathologies is 19.52% in front of 23.67%. All these differences are significant according to a model adjusted by age, sex and comorbidity. The probability of readmission within 52 weeks of discharge for chronic pathologies diminishes of 0.35 in the group of Catalonia to 0.25 in the Baix Empordà. In 2012 Hospital of Palamós obtained a level of satisfaction of 8.89/10, situated it in the top1 of hospitals of similar characteristics (1 of 22) and in the top4 of the group of hospitals of Catalonia (4 of 58). In the same year, all the centres of primary assistance had a level of satisfaction (between 7.99 – 8.30/10) above the average of Catalonia (7.9/10). In a qualitative study about continuity of care between primary and specialized level Baix Empordà is generally better qualified than two other areas in Catalonia managed by other providers of service. Healthcare expenditure in 2012 was of 731€ per person. Pharmaceutical expenditure was 10% lower than Catalonian adjusted by age, sex and comorbidity. Conclusion : Although it is not possible to establish a cause-effect relation between managerial strategies utilized in SSIBE and the good performance results obtained it seem to show that the model is effective and sustainable.