Redesigning primary care services in Maccabi

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

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Abstract

Traditionally, primary care services in Maccabi Healthcare Services were provided by a solo practitioner. The redesign concept was based on the "chronic care model" led by a physician-nurse dyad responsible for proactive prevention, life style counselling, treatment and regular follow up of patients. The main objective is to improve the quality of care. Since 2007 the model is implemented in 50 clinics. Consultation with patients is planned for further improvement of the new model.

Purpose of health policy or idea

The objective of the new policy is to improve the quality of community-based care in Maccabi, while focusing on primary care as the main arena for change. Maccabi Healthcare Services, the second largest health plan in Israel, provides care for 25% of the Israeli population. Traditionally, primary care services in Maccabi were provided by a solo practitioner, who provided "reactive care" for patients who initiated a visit when they felt ill. Prevention and health promotion were episodic and not always regarded as an integral task of the primary care clinic. In 2004, Maccabi started a strategic review process as to the way that its primary care services are being provided, and decided to adopt and implement the concept of "redesign" of the current system of healthcare provision.  

The new model that is currently being implemented in 50 primary care practices is based on five principles:

1. Care is provided by a multi-disciplinary team responsible for ongoing aspects of  their patients' health. The team is led by the physician-nurse dyad, and includes other healthcare professionals as well.
2. In this model, physicians have a defined community of members they are responsible for, and are expected to proactively invite patients for health promotion, preventive care and follow-up on chronic conditions. These services are provided in cooperation with the nurse, who functions as a 'care coordinator".
3. The organization and the content of the physician-patient encounter in primary care better achieves its aims: the encounter is used for comprehensive management of patients' health (e.g. life style counselling, periodic tests for chronic patients, identification of emotional distress etc); planned visits with sufficient amount of time are allocated for these activities; nurses manage encounters that are dedicated to the follow-up and maintenance of chronic care.
4. One-stop-shopping for preventive care by offering all routine check up procedures at  the clinic, or another location, during one visit.   
5. Care is "patient-centered", i.e. care that takes into account patients' values and wishes as part of the clinical decisions, and provides patients with tools for self-management of chronic conditions as well as for maintainig their health on a regular basis. 

The incentives for physicians to adopt the new model include:

• an opportunity to improve the health of their patients, as well as their performance in a set of 25 clinical performance measures monitored continuously by Maccabi; 
• the teamwork will provide the physicians with more time for the clinical tasks that are sometimes abandoned because of time limitations, and might increase job satisfaction 
• physicians joining the new model receive funding for hiring a nurse practitioner, who is trained to work in the new model.

Main points

Main objectives

Improving the quality of primary care.

Type of incentives

• Improved performance in quality measures that are being monitored
• funding of a nurse
• increased job satisfaction

Groups affected

Primary care physicians - will adopt a new model of care. They need to redefine their role as solo practitioners and adopt a new work model, Patients receiving care from caregivers adopting the new model will receive improved care that is more responsive to their needs and enables patient empowerment, Nurses' jobs will be redifined as "care coordinators" with more responsibility and collaboration with physicians and other health professionals.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Innovation - the model is innovative in Maccabi Healthcare Services, but some of its components have been implemented elsewhere in Israel (Clalit sick fund) and abroad.

Controversy - after 2 years of skepticism, most managerial levels in the central administration as well as the majority of the regional managements, are ready to incorporate the model as an integral part of their workplan. 

Systemic impact - the new model will create a significant systemic change in Maccabi since it changes the model of primary care provision and the implicit contract with patients.

Public visibility - this has been episodic and probably ineffective: the patient treated by the redesigned "Personal Physician" clinics were not necessarily aware of the new model of care. We hope that the implementation of the consultation model will increase the model's visibility.

Transferability - the model is transferable to other systems, but would need some adaptation to the existing local service provision models.

Political and economic background

Complies with

In 2004, the Ministry of Health has established a national program for measuring the quality of care provided by the 4 health plans. This has contributed an external motivation to improve performance by redesigning primary care.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

Since 2004, Maccabi's organizational strategy has given high priority to chronic care management as an integral part of the redesign of primary care services. The practical implications of this decision were:

• reorganizing the nursing services to train nurses as care coordinators; 
• development of information infrastructure to support the change in work routines; 
• encouraging physicians to be partners in developing the new model; 
• ongoing monitoring of clinical performance measures that are expected to improve if the new model is adopted (e.g. diabetes management and control, influenza vaccinations); 
• providing funds to physicians joining the new model for hiring a nurse; 
• training of "quality leaders" among healthcare professionals in managerial positions. These quality leaders received formal training in quality improvement methods as well as encouragement to initiate improvement processes and disseminatethem to others. As part of their activities they are encouraged now to adopt the new model of primary care and disseminate it to other physicians and nurses. 

One of the driving forces behind this change was the division for quality management that saw the new model as an effective strategy to improve quality of primary care, a strategy that has been succesfully adopted by various health plans in the last decade, especially in the U.S.

Following the establishment of the 2004 Ministry of Health (MOH) national program for measuring the quality of care provided by the 4 health plans, Maccabi has decided to expand the model for care of chronic patients to include health promotion and prevention for all patients.

In 2005/6 some components of the model described above were implemented in 11 pilot clinics in the 5 regions of Maccabi. The model implemented then was named the "Personal Physician" and included mainly physician-nurse cooperation and some physician initiated visits for follow-up of chronic patients.   

In 2007 Maccabi decided to expand the model from a pilot to an established program which is incorporated into the organization's daily routine. The model was presented as a "redesign" of primary care services with structured processes and protocols for implementation. This change occurred after two years of implementation of the "Personal Physician" model during which it was demonstrated that the model is feasible and well accepted by both physicians and nurses.  

The model is new in Maccabi, but is known in the literature. Some aspects of the model (multidisciplinary team responsible for a defined community of members, with a proactive approach to care provision) can be found in the "primary care clinic" model which is the prevalent model of care in Clalit Health Care services, the largest sick fund in Israel. The other aspects are an innovative development of Maccabi, based on international models.

Initiators of idea/main actors

• Leistungserbringer: Maccabi Health Care Services

• Patienten, Verbraucher

• Andere

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Pilot project - 11 clinics distributed in all 5 regions of Maccabi during 2005-6, originally named the "Personal Physician" model. In 2007 the project was enlarged to a "redesign" concept, with structured processes and protocols for implementation.

Stakeholder positions

Health Division (central medical management), Quality Management and Nursing Management in Maccabi Central Management were partners in formulating the model and evaluating  its imlplementation. They support the model and as part of their partnership, continuosly discuss difficulties and opportunities and conduct the required adaptations of the model.

Regional management of the 5 Maccabi  regions - are responsible for implementation of the model. In the first two years of implementation, a 'sitting on the fence' attitude has chracterized the regional response: "we shall do whatever central management requires, however we do not have a strong belief in the change or its chances of success". In 2007 a better commitment has developed.

Maccabi primary care physicians (PCPs) and their union - 90% of PCPs are independent physicians represented by a union named 'The Organization of the Independent Phsycians of Maccabi". The PCPs joined the program at a moderate pace, attributed to a probable combination of the fear of change and the lack of strong support by their representatives ("union"). A constant support by the Central Executive Officer (CEO) and the Central Medical Officer (CMO), who led a dialogue with the physicians and their representatives, helped dissolve the initial overt objection on the part of the union.

Maccabi nurses -  both headquarters and nurses in the field realized the potential benefit to the nursing profession and supported its implementation. Nurses were required to introduce a huge change in their former working processes as a result of implementing the new model.

Maccabi members are yet unaware of the radical change planned with regard to the way that primary care services are provided. Currently, most Maccabi members are used to the traditional way of care provision in Maccabi, where the main partner for encounters with the system is the solo PCP, while the nurse is practically invisible or just "takes blood pressure measurements" - usually in a central location (not in the PCP's clinic). The redesign requires - prior to full adoption - a structuerd dialogue for the purpose of consultation with Maccabi members, as to the model that would best fit their expectations.

Specialists - the model may probably shift the existing balance from specialty care to primary care. The full implications for secondary care are unclear at the moment; however, a strong objection from the specialists might follow wide-scale implementation.

Actors and positions

Leistungserbringer
Maccabi Health Division	sehr unterstützend		stark dagegen
Quality Management department	sehr unterstützend		stark dagegen
Nursing Management department	sehr unterstützend		stark dagegen
Regional management	sehr unterstützend		stark dagegen
Maccabi primary care physicians	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Maccabi members	sehr unterstützend		stark dagegen
Andere
Maccabi nurses	sehr unterstützend		stark dagegen
Maccabi specialists	sehr unterstützend		stark dagegen
Organization of independent physicians	sehr unterstützend		stark dagegen

Influences in policy making and legislation

Not relevant.

Legislative outcome

n/a

Actors and influence

Leistungserbringer
Maccabi Health Division	sehr groß		kein
Quality Management department	sehr groß		kein
Nursing Management department	sehr groß		kein
Regional management	sehr groß		kein
Maccabi primary care physicians	sehr groß		kein
Patienten, Verbraucher
Maccabi members	sehr groß		kein
Andere
Maccabi nurses	sehr groß		kein
Maccabi specialists	sehr groß		kein
Organization of independent physicians	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

Pilot projects "Personal Physician" in 2005/6

In 2005-6 the pilot project of the "Personal Physician" implemented in 11 clinics was given relatively "loose" instructions as to implementation. As a result, wide diversity in implementation prevented any valid evaluation of the results. However, semi-structured interviews and observations in the clinics implementing the "Personal Physician" model led to the following understanding:  

• the working processes, especially the incorporation of a nurse in the PCP clinic, are effective and should be adopted;  
• the model should be expanded to create an organizational  "momentum", necessary to nourish such a cardinal change;  
• formats and protocols should be written and provided to the clinics as a "roadmap" for implementation, in particular protocols for the nurse as care coordinator; 
• the staff, and primarily the nursing staff, should be trained for the new work environment;  
• regional managerial support and attention are critical for success.  

Implementation of advanced model

Consequently, the following steps have been taken for implementation of the new model:

1. Regional managements have been given quantitative goals based on the planned pace of growth of the model (50 new clinics per year, starting in 2007) and the size of the region. Close follow-up was carried out.
2. Senior nurses were recruited and training programs have begun.
3. A manual with clear protocols and working processes has been written by the group in charge of developing the model, in consultation with the regions. The group included senior officials in the central administration of Maccabi;  the members of the steering committee are: Dr. Kukia, Dr. Meyron, Dr. Kedem, Dr. Heymann, Ms. Goldman and Ms. Shem-tov from central headquarters.

Monitoring and evaluation

The evaluation will address two processes:

• Redesign of primary care services: an evaluation of structure (staff training, number of clinics in the model etc); process (detailed evaluation has been planned for numerous components of the new work process); and of clinical outcomes (effect on patient quality indicators and satisfaction with the model). This evaluation will be an integral part of implementing the model.
• Consultation with a representative sample of Maccabi members as to the model and its implementation: The evaluation will measure the impact of the consultation process on the following outcome variables: 
  - Patients' knowledge and information recall
  - Organizational decision making
  - Partner experience (management, professionals, public representatives),
  - Managerial attitudes as to the value and effectiveness of public involvement in policy making
  - Clinical quality and patient experiences with the health care provided by the health plan (in all likelihood, this is a delayed effect and may not be found appropriate for evaluation after a single consultation session).

Review mechanisms

Halbzeitevaluation, Abschlussevaluation (intern), Abschlussevaluation (extern)

Dimensions of evaluation

Struktur, Prozess, Ergebnis

Results of evaluation

No results yet.

Expected outcome

New model will improve quality of care

The new model of primary care delivery is expected to achieve its main objective - improve the quality of care, as measured by a broad set of performance indicators. This expectation is based on the international literature that shows the advantages of  the "Chronic Care Model" (Bodenheimer et al. 2002 ) which is a basic aspect of the Maccabi model, and the advantages of the principles of the  implementation process that  Maccabi adopted (see section "Purpose of health policy or idea; Wang et al. 2006).

Maccabi has also established an extensive set of measures that will focus on the structure and working processes of the redesign model itself (e.g. percent of patients who participated in establishing their own 'therapeutic contract' and goals). The monitoring and  measurement are expected to induce PCPs and nurses to implement the model in their daily practice.

Other expected outcomes are:

• increased patient satisfaction (general member satisfaction as well as satisfaction of chronically ill members),
• increased job satisfaction among PCPs and nurses, and 
• in the long run - a balance between the cost of the model (increased staffing, IT infrastructure) and the savings resulting from improved health, especially among the chronically ill patients.

Consultation with Maccabi members is to improve satisfaction

The consultation with member representatives as to the formulation of the model is expected to improve member satisfaction, contribute to decision-making that will  better take into account the voice of the consumer, which will possibly improve clinical outcomes in the long run (data in the literature is still inconclusive as to these effects).

Undesirable effects of the new model

A serious undesirable consequence may be financial instability of the health plan, which may result if the huge investment in staffing and extra managerial efforts may not contribute to decreased expenses (an expected result of improved quality of  care). Careful ongoing monitoring may forsee these consequences and respond accordingly.

Also, as previously mentioned, the shift towards empowerment of primary care may  negatively affect Maccabi's relations with its physician representatives. Finally, some believe that consultation with the public might  raise skeptical attitudes on the process from both managers and the public.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Quality of health care services - is expected to improve significantly. However, for reasons mentioned above, it is too early to assess the effects on quality. These will probably be seen towards the end of 2008. The expected improvement is related to enhanced continuity of care, comprehensiveness of care and responsiveness to patients' preferences and values.

Equity - is expected to increase because a central component of the program is intensive outreach efforts (particularly by nurses) to bring non-compliant patients for follow up and care. It is expected that this focused intervention will be especially beneficial and effective in less advantaged populations who are known to be less compliant today.

Cost efficiency - is expected to improve based on evidence from the literature. Studies indicate that after 2-3 years of implementing the chronic care model a return on investment can be seen - the improved quality of care reduces costs related to deterioration of condition (e.g. hospitalization).

References

Sources of Information

• Wilf-Miron, Rachel, Kedem, Hagai, Heymann, Anthony, Goldman, Dorit, Kukia, Ehud, and Orna Shem-Tov. Redesign of community-based health services: The solution for decreasing the quality gap. Harefoa (forthcoming, in Hebrew).
• Bodenheimer, T, H.Wagner, E, and K. Grumbach. "Improving primary care for patients with chronic illness. The chronic care model." Journal of the American Medical Association 288 2002. 1775-1779.
• Bodenheimer, T, Wagner, E, and K. Grumbach. "Improving primary care for patients with chronic illness. The chronic care model, part 2." Journal of the American Medical Association 288 2002. 1909-1914.
• Wang, MC, Hyun, JK, Harrison, M, et al. "Redesigning health systems for quality: Lessons from emerging practices." Joint Commission Journal of Quality and Patient Safety 32 (11) 2006. 599-611.
• Coulter, A, Ellins, J. Patient-focused interventions. A review of the evidence. Picker Institute Europe, August 2006.
• 6. Involve & togethercan. People and participation. London: Involve. 2006.

Author/s and/or contributors to this survey

Wilf-Miron, Rachel, Kokia, Ehud and Revital Gross

Dr. Rachel Wilf-Miron is the director of Quality Management in Maccabi Healthcare Services; Dr. Ehud Kokia is the CEO and temporarily also the CMO of Maccabi Healthcare Services;  Prof. Revital Gross is a Senior Researcher at the Myers-JDC-Brookdale Institute.

The program described in this report was developed and is being implemented with the support of a steering committee including: Dr. Hagai Kedem, Dr. Anthony Heymann, Ms. Dorit Goldman and Ms. Orna Shem-Tov.

Empfohlene Zitierweise für diesen Online-Artikel:

Wilf-Miron, Rachel, Kokia, Ehud and Revital Gross. "Redesigning primary care services in Maccabi". Health Policy Monitor, September 2007. Available at http://www.hpm.org/survey/is/a10/3