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
Disposition
• Frank
• Strategy for quality
• Healthcare data
206-10-2016
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.
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.
Franks health
• COPD
• CHF
• Diabetes
Reality about Frank
• Frank IS in control
• Frank cost a lot of money
• Frank gets worse
• Nobody knows Frank
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
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
Traditional segmentation
all patients with hypertension
New segmentation
sociopsychological issues
• “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
Mega trends – infliction point
• Mega trends tag fra Mike Wagner
• - specialization
• - chronic diseases
• - demografi 12
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Strategy to improve the quality of care - The Juran trilogy
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Multi-level model
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• Set direction and priorities
• Bring clarity to quality
• Measure and publish quality
• Recognise and reward quality
• Safeguard quality
• Building capability
• Stay ahead
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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
• Access to data is granted
• Demand is there
1706-10-2016
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
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06-10-2016
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
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