HOW IT WORKS
In this population-based integrated care program, a regional integrator (health management company), together with general practitioners (GPs) and specialists, works with the patient to develop an individualized care plan. The plan integrates a wide range of health care and community services, including sports clubs, community associations, and patient groups. The program supports patients’ personal goal-setting and self-management activities and provides coaching to doctors on shared decision-making. It is supported by a sophisticated data infrastructure in which partnering health insurers share timely administrative data with providers to help them improve quality and care coordination. Referral to the program — by the GP or another physician designated as the “doctor of trust” — is based on a patient questionnaire, a comprehensive GP assessment, and health coaches who are part of the regional health management company.
The program has been operating in one area of Germany since November 2005 and has been expanded to different regions in Germany (including two low-income neighborhoods in Hamburg and new a rural area in Hessen) and abroad (the United Kingdom and the Netherlands). The program has been evaluated by funders and external researchers and a review of these evaluations reports positive impacts on health outcomes and patient experience as well as reduced costs. It is being evaluated as part of SELFIE (Sustainable Integrated Care Models for Multi-morbidity: Delivery, Financing and Performance), a Horizon2020 EU project using standardized metrics, quasi-experimental comparisons to control populations, and a common research methodology (multicriteria decision analysis).
For providers. Physicians (and other health professionals) get support in managing complex patient situations and lifestyle changes and are paid for extra time spent on management. Physicians receive advanced education on caring for patients with multiple chronic conditions. The program also empowers doctors to better manage their patients’ care through integration with local electronic integration and a range of health and social services. Providers have access to each other’s data on patients’ medication, use of antibiotics, and polypharmacy and are encouraged to make comparisons.
For patients/caregivers. Patients are at the center of this program and are free to participate (without restriction). They codesign an individualized, integrated health and social care plan for managing their multiple chronic conditions with the help of their doctor-of-trust and trained health coaches employed by the regional health management company. The program provides access to a range of health and community services that support their care plan. The doctor-of-trust and the health coaches work closely with the patient on self-management and on strategies for appropriate lifestyle changes. This program focuses on high-need, high-cost patients but also emphasizes prevention, health promotion, and public health to generate value for the population in the long run.
The program is a structured partnership between a regional health management company (i.e., accountable care organization) and health insurers, a range of health and social care providers, and physicians of all kinds. The regional company, owned partly by local health provider networks and partly by the Hamburg-based health sciences company OptiMedis, establishes service contracts with health and social care providers, helping to overcome fragmentation in care, enhance better follow-up on care transitions, and improve communication among health and social care providers. Patients’ direct engagement with the program is essential to activate and engage them in improving their health status and self-management capacity.
A robust financing and reimbursement model that benefits all partners is at the core of the program. Insurers’ costs for the entire Kinzigtal population are more than 5 percent lower compared to a similar population, and they still save more than 2 percent after splitting savings with the regional health management company. The regional health management company invests in: staff for coordinating care; training for health coaches, providing health courses, data analysis and processing, and extra time needed by physicians and other providers to care for and support patients.
Contact: [email protected]
International website: https://www.gesundes-kinzigtal.de/international-website/
Additional information on impact: Summary of previous evaluations: https://healthpolicy.duke.edu/sites/default/files/atoms/files/germany_25jan2017.pdf.
A summary of the research design and methods for the SELFIE evaluation is available at https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/s12913-018-3367-4.