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(1)

WHINN 2016

Integrating Health and Social Care

- A regional perspective on integrated care

Chief Operating Officer Jens Winther Jensen, MD, Region of Southern Denmark

06-10-2016

1

(2)

Disposition

• Frank

• Strategy for quality

• Healthcare data

2

06-10-2016

(3)

Vision

A Native Community

that enjoys physical, mental, emotional and spiritual wellness

Mission

Working together with

the Native Community to achieve wellness through health and related services

Copyright © 2011 Southcentral Foundation. All Rights Reserved.

(4)

Frank

Frank

Frank is a 79 year old widower with

Chronic Obstructive Pulmonary Disease

(COPD), Heart Failure and Diabetes. He lives alone.

Frank is very anxious as he is often very breathless and feels unable to manage. He has phoned the practice

of his primary care physician on several occasions

requesting a home visit and over the last year he has frequently been taken to the local emergency

department, after he has dialled 911. He has been admitted to hospital on 7 occasions in the last year and now keeps a small packed suitcase by his chair.

Copyright © 2011 Southcentral Foundation. All Rights Reserved.

(5)

Franks health

• COPD

• CHF

• Diabetes

(6)

Reality about Frank

• Frank IS in control

• Frank cost a lot of money

• Frank gets worse

• Nobody knows Frank

(7)

NUKA to a different look at Frank

• Primary diagnoses

– Anxierty, lonelyness, isolation, confusion, dependence, lack of self confidence Sekundære diagnoser

– COPD, CHF og diabetes

• Primary interventions

– Integration of services, medicine check up, plan to fight isolation

(8)

Copyright © 2011 Southcentral Foundation. All Rights Reserved

Anchorage Area Patients

Visits to ER/Urgent Care Per 1000

200 400 600 800 1000 1200 1400 1600

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Number of Visits

Day per 1000 Night per 1000

Better Native

ownership begins

Anchorage Area Patient

Visits to ER/Urgent Care Per 1000

(9)

Traditional segmentation

all patients with hypertension

(10)

New segmentation

sociopsychological issues

(11)

• “The sicker one is, the more socially and medically

complicated one is, the less our current system of care meets their needs and the more such individuals are on their own,”

Robert Masters, MD

(12)

Mega trends – infliction point

• Mega trends tag fra Mike Wagner

• - specialization

• - chronic diseases

• - demografi 12

06-10-2016

(13)

Strategy to improve the quality of care - The Juran trilogy

13

06-10-2016

(14)

Multi-level model

14

06-10-2016

(15)

Set direction and priorities

Bring clarity to quality

Measure and publish quality

Recognise and reward quality

Safeguard quality

Building capability

Stay ahead

15

06-10-2016

(16)

Indicators

Local goal

Local goal

Local goal

Local goal

Local goal

Local goal

Local goal

Local goal

Local goal

Local goal Hospital

Hospital

Municipality Hospital

Municipality Municipality

Local goal

Local goal

Local goal

Local goal

Local goal

Local goal

The national goals

National LevelLocal leveL

The patient as the center

Improved efforts for the chronically ill and elderly patients More coherent

continuity of care

Improved survival and patient safety

Treatment of high

quality Rapid diagnosis and Rap

treatment Increased patient Rap

involvement More healthy live Rap

years More effevtive Rap health care

Indicators

Indicators

Indicators

Indicators

Indicators

Indicators

Indicators

Hospital

GP

GP

(17)

• Access to data is granted

• Demand is there

17

06-10-2016

(18)

Privatization of health data

• Advances in technology and analytics to

radically improve care is the principle motivator for many companies

• BUT data is sequestered in “closed loops”

• Data hard to get

• Hamper scientific progress by blocking the discovery of new ways to interpret data

18

06-10-2016

(19)

Personal healthcare data under democratic control

• Networks with sufficient numbers of patients and citizens who are motivated to feed their data

• Knowledge resource could be used to identify best course of treatment for an individual on the basis of the experience of thousands

• Data should be a public good

• Services that translated these data into value could be closed

19

06-10-2016

(20)

CPR number

Biobank Genom bank

Clinical data

Personal data

The unique possibilities in Denmark

(21)

Referencer

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5th October 2016 WHINN 2016 - Odense, Denmark - Integrating Health and Social Care 34.