|Implemented in this survey?|
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.
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:
The incentives for physicians to adopt the new model include:
Improving the quality of primary care.
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.
|Medienpräsenz||sehr gering||sehr hoch|
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.
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.
|Implemented in this survey?|
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:
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.
The approach of the idea is described as:
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.
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.
|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|
|Maccabi members||sehr unterstützend||stark dagegen|
|Maccabi nurses||sehr unterstützend||stark dagegen|
|Maccabi specialists||sehr unterstützend||stark dagegen|
|Organization of independent physicians||sehr unterstützend||stark dagegen|
|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|
|Maccabi members||sehr groß||kein|
|Maccabi nurses||sehr groß||kein|
|Maccabi specialists||sehr groß||kein|
|Organization of independent physicians||sehr groß||kein|
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:
Implementation of advanced model
Consequently, the following steps have been taken for implementation of the new model:
The evaluation will address two processes:
Halbzeitevaluation, Abschlussevaluation (intern), Abschlussevaluation (extern)
Struktur, Prozess, Ergebnis
No results yet.
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:
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.
|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).
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.