01.02.13
Managing highly complex patients through integrated care
Source: National Health Executive Jan/Feb 2013
The Healthcare Financial Management Association (HFMA) is working with Net.Orange on an integrated care project, involving HFMA’s trading subsidiary HCS. NHE hears more about the project from HCS director Martin Walsh and Net.Orange chief medical officer Dr Rob Beardall.
The push to integrate health and care services has two core drivers: patient outcomes, and reduced system-wide costs.
Martin Walsh, director of HCS, told NHE: “That gets to the nub of why HFMA are involved in this partnership with Net.Orange. When you look at resources, the NHS has to manage the patient population. At all times, no matter what the state of the public purse, there’ll always be an element of clinical or financial risk associated with the management of patient populations, managing the resources in the most effective way.
“You can’t separate those two: there isn’t really much of a gap between the financial and clinical risk that an organisation faces.”
Dr Rob Beardall, chief medical officer at Net.Orange, said his time as a chief medical information officer in the US had brought him perspective on this; he was involved with Exempla Healthcare’s ‘virtual integration’ with Kaiser Colorado, and with Fletcher Allen Healthcare, the University of Vermont, and the United States military as a flight surgeon. He said: “It’s impossible to separate clinical quality and clinical outcomes from more cost-effective delivery.
“Look at the variety of different care delivery models that exist across Western medicine – I say delivery models, not payment differences, because the integrated models in the States, delivered to a relatively small segment of the population through organisations like Kaiser and Geisinger and the VA [Department of Veterans Affairs], provide care to a defined population.
“They do that and get much better clinical outcomes, they’re much more cost-effective, and patient satisfaction and provider/staff satisfaction is higher – because there’s a joinedup perspective on what the goals are, what the gameplan is for managing those patients, typically the higher-risk patients within a given population.
“We don’t necessarily need an integrated care model for an 18-year-old who sprains his ankle. But we do need integrated care to manage the highly complex, very high-cost patients who are a relatively small percentage of the population in total – in the UK, something like 6% of the population consumes about 50% of the resources. There are exceptions – multiple trauma patients are obviously very expensive as well – but the majority of these patients have chronic conditions, and they require a joinedup, integrated care model.
“There needs to be a team-based approach to managing those patients across organisational boundaries, across teams within organisations.”
Praising the work of people like Chris Ham at The King’s Fund, and the Nuffield Trust, Beardall said: “I think we’re finished debating if integrated care is necessary: the partnership (and I’m biased) is really looking beyond that debate. It’s intended to help organisations actually start doing it. What I’ve seen in the NHS is various pieces and parts of what an integrated model would look like, but they’re not connected, and so the approach with HFMA is ‘let’s help organisations accelerate the pace of actually implementing this and getting it done’.”
The role of IT
At the heart of the partnership is that HCS will distribute Orange.Net’s clinical operating system, described in the statement announcing the partnership as “a real-time, cloud-based data integration platform”, and its population health management suite of applications.
But as Walsh explained: “The services we’re offering are not necessarily a ‘technology sell’. It is really about how you’re managing patients, and helping shift the care delivery model to a more proactive one.
“For organisations to be able to do that, yes IT is an enabler, but it’s not the only enabler. Having complete transparency on how multidisciplinary teams are managing provision of care and providing the necessary decision support all along that journey is critical.
“Also critical from the structural level is having the right clinical governance arrangements in place across the health economy. So, members of the clinical teams in an acute setting, or a social care setting, or mental health in community or primary care settings, are all involved in that governance model where relevant.
“But also, in terms of the integrated care model, it’s about organising those MDTs and developing the care pathways that are necessary to be able to deliver more optimised care.
“If you’re shifting the settings of care for some patient populations, then some organisations win, some lose, under current models, and it’s important for the whole health economy to effectively ‘win’ from managing care in this way. It’s better for the patients, and it should be better for the organisations as well.”
Providers or commissioners – who should lead?
Dr Beardall said in general, he thinks commissioners should play a facilitative rather than directing role.
He explained: “It’s critical that all the key stakeholders are engaged and involved, but that being said, generally speaking, the acute trusts within a given health economy have a higher degree of management capability, skills and resources.
“It takes leadership and a vision of how things can be different. It takes identifying some parochial behaviours and setting those aside, with a view towards what the fi nancial impact.”
Dr Beardall explained that he originally moved from the USA to the UK to help Mike Farrar when he was chief executive of NHS North West, and he spent 18 months on the World Class Commissioning initiative.
“I do understand the commissioning perspective very well,” he said. “One of the things PCTs fell short on was truly engaging the various stakeholders in creating shared decision-making, as opposed to dictating what should be done. Commissioners don’t have all the ideas, or all the answers: there has to be a multi-disciplinary approach.
“But the commissioners bring value to the conversation by painting a picture at a population level that the individual providers may not have.”
The partnership
Explaining the genesis of the partnership, which was solidified in autumn 2012, Walsh told us: “Our trustees asked me to look out to the UK marketplace, where there were a lot of organisations talking about real-time decision support and being able to fi nancially risk-assess the whole patient population and provide the tools to do it.
“But when you look under the bonnet of a lot of the services out there, we felt that to do this effectively, we had to look to other industries in the way they manage products and services in a cost-effective way. The notion of supply chain automation that’s used in retail and fastmoving consumer goods, and the financial services industry, is a very apt one in healthcare as well.
“We started speaking to Net.Orange at the end of November 2011, and it was a very good fit.
“Net.Orange’s founder’s [Vasu Rangadass] background was in those other industries, and he built systems for companies like Walmart, Tesco, M&S, Dell, Pepsi, lots of others.
“Healthcare is different – but the approach to managing multiple suppliers to a service that is complicated but needs a joined-up approach is not so different.”
“We feel the technology Net.Orange offers is a signifi cant departure from the kind of IT infrastructure capabilities that have been built in this country historically. We don’t feel necessarily that orgs need to spend millions of pounds on software and implementation costs unnecessarily. They should focus their resources on where the population needs it and where their organisation is most at-risk.
“We developed the partnership following some joint work with pilot organisations over nine months, including having sight of the work that had been done in Southport & Ormskirk, but also with other health economies as well. For Net.Orange the benefi t is obvious; HFMA has got a signifi cant profi le at board level across the NHS, and wants to use that to infl uence the way organisations are managing care, in the same way HFMA does. We’ve got a professional interest in supporting the NHS to deliver the kind of transformation that’s needed to support the delivery of care in the most cost-effective way. We’re excited about it.”
Tell us what you think – have your say below, or email us directly at [email protected]