|Integration of care after the 2005 health reform|
|Implemented in this survey?|
In 2006, State Health Agencies and its Health Platforms were established in each of Austria?s nine federal states. One of the goals was to improve planning, controlling and financing of the health system by overcoming sectoral boundaries. To achieve this funds may be earmarked ("reform pool") to compensate for shifts in service provision between health care settings (see also survey (7) 2006). This survey gives an overview about "reform pool" activities in Austrian federal states.
In March 2007 we conducted a survey to gather information on the status of the implementation of "reform pool" projects (the questionnaire is available from the authors). Standardized questions were sent out to all offices of State Health Agencies and their supreme bodies, i.e. "health platforms"; with the exemption of Salzburg and Lower Austria (information from the webpage) all State Health Agencies replied and provided information. The degree of implementation of "reform pool" activities varies across federal states. In some federal states the health platform boards have already decided on specific "reform pool" projects and the implementation has already started. In other states decisions on "reform pool" projects are pending. In the following we report on major developments in each federal state in this area.
No formal descisions are yet being made on "reform pool" projects. In its meeting on March 27 the health platform Vienna envisaged to discuss five projects:
1.) General Hospital of Vienna (AKH): Physician Radio Service for children's outpatient department.
The idea of this project is to substitute treatment of non-severe cases in the children's Department of Vienna's General Hospital with treatment of these cases by pediatrists of the Physician Radio Service. Especially on weekends the pediatrists will be dispatched by the physician radio service. Patients are either treated at home or in the physician radio service's medical center. The goal is to reduce the workload of the overcrowded outpatient service of the children's department in Vienna's General Hospital.
2.) Integration of care: stroke (phase 1)
This project aims at optimising and fast-tracking the allocation of patients to reduce long-term consequences. In the first project phase, information and data will be gathered and possible cooperations between actors will be explored.
3.) Discharge managment
The objective of this project is to improve the managment of discharges. Four coordinated measures, i.e. the management of discharges, standardised information transfer, support groups in hospitals and online information, like www.lebensseiten.at are to improve the management of hospital discharges and minimize friction; patient interests are to be strengthened and the availability of information is to be increased. The scope of this project goes beyond current guidelines for funding from "pooled" money. It is thus envisaged to promote financial incentives for actors involved.
4.) Diabetes Mellitus, Type 2 management
The goal of this project is to improve quality of life and enhance life expectancy of diabetes patients. Measures envisaged to support implementation are patient empowerment, training for physicians, evidence based treatment paths, quality assurance and economic evaluation.
5.) Viennese Danube Hospital: general practitioner service
This project seeks to reduce the workload in hospital outpatient departments allowing them to concentrate on more complex cases. The Physician Radio Service should take over the treatment of patients with defined "light" disorders. It is expected that at least ten percent of the patients could be taken care of outside hospitals. The Physician Radio Service is planned as an emergency medical aid. Follow-up treatments will not be carried out by the Physician Radio Service.
In 2006, the Health Platform of Carinthia decided on two specific "reform pool" projects.
1.) Diabetes Mellitus Type 2 training courses for patients.
Diabetes Mellitus Type 2 training courses for patients are to be extended to insulin-dependent diabetes patients. Patient education is recognized as a preventive and therapeutic instrument that should enhance the patient's knowledge about their disease. Until now the training took place in hospital departments. It is intended to shift the courses to general practitioners and to specialists in private practices. The inpatient care sector only organizes the allocation of patients and offers infrastructure for outpatient service providers. To realize the project's goals it is planned to increase the number of training centers to reach an area-wide coverage in Carinthia.
2.) Improving access to speech therapists
Carinthia has currently no contracted speech therapists. Hospitals are faced with excess demands resulting in long waiting times. The Social Health Insurance fund Carinthia will offer contracts for speech therapists in private practices provided a certain level of work experience is guaranteed. To achieve this, five additional positions for graduated speech therapists will be created in Carinthian hospitals in fall 2007. These job openings will be financed by the Carinthian State Health Agency for one year. Following this year of intramural on-the job training speech therapists will receive contracts to work in private practices. It is envisaged that access to speech therapists is improved and waiting times in hospitals reduced.
In November 2006, the Health Platform of Upper Austria decided on two specific reform pool projects:
1.) Diabetic care (DIA) Upper Austria (project time: April 2006 - September 2008 incl. evaluation)
In cooperation with diabetes experts, the federal state and the local doctors chamber, the Upper Austrian Sickness Fund developed a concept for structured care in outpatient practices for Diabetes Mellitus Type 2 patients. The project was piloted in selected rural areas for two-years ("Diala") and will be launched at the state level (see below).
This project aims at enhancing coordination between general practitioners and specialists (e.g specialist for internal medicine, ophthalmologists, orthopaedists, neurologists, urologists, dermatologists) and hospitals. The objectives are to prevent (neuropathic) symptoms of the disease, negative effects of the therapy and eye and kidney complications. It also seeks to reduce cardiac morbidity and mortality and to increase quality of life. It is expeceted that overall cost will be reduced in inpatient care and in the outpatient sector.
2.) Integration of care: stroke
This project aims at enhancing coordination of care across care sectors to increase process and outcome quality. At the beginning of the project the focus is on increasing treatment quality. Transparency, sustainability and patient orientation are to be improved by introducing structured information exchange and a data warehouse which may be accessible to all cooperating actors (rescue organisations, hospitals, rehab-centres).
In Burgenland, six projects have been proposed. The decision on three specific projects is scheduled for April 18:
1.) Diabetes: Disease Management Program (DMP) - "Model Burgenland"
The project aims at early detection of diabetes, delaying and preventing disease progression, improving quality of life and enhancing self-care. It is also envisaged that system costs will be reduced.
2.) Prevention of colon carcinoma - "Burgenland against colon carcinoma"
This project aims at improving the early diagnosis of the malignant colon carcinoma. Awareness should be raised that colon cancer is preventable, e.g. with an endoscopic excision of prestage colon carcinoma.
3.) Child Psychiatric Counselling Center Eisenstadt
This "reform pool" project seeks to ensure the provision of outpatient child psychiatric care and care for juvenile drug addicts in the region. In addition the project aims at coordinating admissions to inpatient care across regions as capacity is scarce in Burgenland.
Furthermore three other projects have been proposed but have not yet matured for decision.
1.) Admission management - preoperative diagnostic screening
2.) Management of hospital discharges
3.) Hospice and palliative care
The Health Platform of Lower Austria decided on seven "reform pool" projects in 2006. In a first phase, the effectiveness of five (listed 1-5) of these projects is to be tested in a model region ("Waldviertel"). If the results are sufficiently satisfying, it is planned to extend the projects to the whole of Lower Austria.
1.) Admission and discharge management (project status: coordination meetings)
This project aims at establishing efficient admission and discharge management in hospitals as well as at improving the interface management in the health system. Binding arrangements between service providers and a standardised documentation is seen as conditional for implementation.
The following impact is expected:
2.) Central multidisciplinary admissions department (hospital Horn) (project status: in use since July 2006; evaluation planned in the middle of 2008)
This project seeks to support quick determination of whether patients need inpatient or outpatient treatment. A multidisciplinary admissions department in the hospital of Horn is to optimize the admissions management.
3.) Coronary heart diseases
This project aims at optimizing care of patients with chronic cardiac insufficiency.
The project compares two follow-up strategies by conducting an experiment consisting of two groups of patients:
4.) Oncology care
This project aims at improving case management of oncology patients. An institutionalisation of personal and organisational cooperation of all actors involved in providing care to cancer patients is planned. The case management concept includes:
5.) Diabetes: Disease Management Program (DMP) (in preparation)
6.) Integration of care: hospice and palliative care (pre-phase)
The objective of this project is the implementation of an effective, region-wide hospice and palliative care program in Lower Austria. The project started in 2005 and is based on three stages. Full implementation is expected by 2012. The integration of hospice and palliative care is to involve existing structures and facilities so that basic care can be provided in a wide range of health care and social care institutions such as private practices, nursing- and long-term care homes, hospitals etc. For more complex cases it is planned to establish mobile hospice teams, mobile palliative teams, palliative conciliar service, palliative departments, inpatient hospice and daytime hospice. Care needs are coordinated by a "care manager" in each of the five health regions in Lower Austria.
7.) Dental treatment for children under the age of 10 years and people with special needs (prephase)
The Health Platform of Tyrol has already decided on four "reform pool" projects. The projects deal with:
1.) Preoperative diagnostics
2.) Expensive pharmaceuticals
2.) Diabetes Mellitus, Type 2: Disease Management Program (DMP)
3.) Stroke: Integration of patient/treatment pathways
All projects are still in preparation - project outlines and project structure plans are currently being worked out. As of now no further information is available. The official launch date of the project has not yet been decided .
No "reform pool" projects have been decided yet. The next Health Platform meeting is scheduled for April 2007, but it is not clear if any specific projects will be decided on. Ideas for projects in the following areas exist but no further information is currently available:
1.) Discharge management
2.) Mobile child nursing
3.) Palliative care
As of April 2007 eight reform pool projects have been initiated or at least agreed upon in Styria.
1.) Nephrology Care in Styria
This project's goal is the realization of an integrated care program for patients with nephritic insufficiency. Following international recommendations, referral guidelines should be implemented to guarantee a timely allocation of high-risk patients to specialists. For secondary prevention, it is planned to establish a curriculum of nephrology care for physicians in practices. Furthermore, patient information is to be provided and specific, area-wide training programs for patients with restricted renal function are to be established in order to prepare patients for the options of renal substitution therapies. In addition it is intended to ensure an area-wide provision of Peritoneal Dialyze, a method that is comparatively less strenuous. Dialyze institutes in private practices and intramural renal units in public hospitals are to cooperate in the project. Additionally, education and information measures are to take place in cooperation with the Styrian doctors chamber and the University Medical Center in Graz.
2.) Coordination of care - interface management in Greater Graz
This project's main objective is ensuring the continuity of care of University Medical Center patients. The project focuses on improving patient satisfaction, reducing unnecessary patient paths and improving sustainability of inpatient treatment success. In order to reduce the length of hospital stays discharge management will be improved. Besides professionals of the University Medical Center Graz (i.e., physicians, nurses, social workers, care coordinators etc.), physicians in private practices and institutions of the extramural sector, e.g. mobile services will participate in this project. By improving post-inpatient care it is expected to reduce re-admissions.
3.) Disease Management Program for Diabetes Mellitus, Type 2.
Due to the positive experience with area-wide training courses for patients suffering of Diabetes Mellitus Type 2, the Institute of Medical Technologies and Health Management and the regional sickness fund decided to develop a Disease Management Program for these patients. The program's goal is to facilitate continuous care for the chronically ill and to improve the level of provision.
The program is intended as a comprehensive tool helping to transgress sectoral boundaries in order to optimize care. Taking an evidence based approach to care and treatment the project looks at diabetes from a more holistic point of view rather than understanding it as a condition consisting of single episodes.
Every patient can register with his or her DMP-physician - preferably with the general practitioner. This physician's task is to coordinate treatment and to guide the patient. In order to facilitate treatment, evidence-based patient-paths have been developed. The patient is to play a more active role in treatment. For instance, patients and physicians should jointly decide on goals they want to achieve. As international examples have shown, such an approach helps reducing long-term complications. Reducing these long-term complications should result in lower future costs of intramural care thereby offsetting the initially higher cost associated with setting up the disease management program.
4.) Provision of Hospice- and Palliative Care
This project's goal is to develop and expand respectively the province's network of tiered hospice and palliative care system. Services range form mobile palliative care teams to intramural hospices all of which closely cooperate. The project is targeted at patients who are terminally ill and who are suffering of progressive sicknesses. Supporting the patients' relatives or close ones is part of the project.
Embracing existing facilities the system takes a tiered approach in providing care at all stages of the health care system. Basic care is to be provided within the existing setting, for instance by the general practioner or a mobile nurse. In more complex cases specialized hospice and palliative care teams consult and or support patients and their relatives. One of the main goals is to reduce the workload of existing structures especially in acute care.
5.) Integrated Care for stroke patients
This project introduces an integrated care program targeted at stroke patients in Styria. The project's goals are increasing the survival rate of stroke patients, reducing the negative long-term consequences of a stroke and advancing patients' return to a normal life. By optimizing process quality and by optimizing existing facilities' full potential the project is intended to enhance the quality of treatment. In order to achieve these goals the projects aims at
6.) Integrated Care for coronary heart diseases and/or coronary artery stenosis
This project introduces an integrated care program targeted at patients suffering of coronary heart disease (CHD) and/or coronary artery stenosis (CAS).
The project's goals are increasing the survival rate of stroke patients, reducing the negative long-term consequences of a stroke and advancing patients' return to a normal life. The project tries to achieve these goals by aiming at well balanced structure, process and outcome quality in diagnosing and treating CHD and CAS respectively. Since appropriate structure quality has already been achieved in Styria, the project's focus is on process and outcome quality. Focusing on process and outcome quality means efficiently and effectively integrating patients into the existing structures of provision and ensuring uninterrupted treatment at all stages of care especially when entering into rehabilitation. These efforts are coupled with a constant evaluation of all aspects of care by using predefined indicators.
Besides pension funds, social organizations, emergency care services, rehabilitation clinics and doctors in private practices three major hospitals in Graz, Bruck/Mur and Deutschlandsberg are currently participating in the project.
7.) Medical Treatment at Home - Hartberg county
This project's goal is increasing the quality of life and the satisfaction of patients, their relatives and health care workers alike by improving the provision of medical care prior to hospitalization as well as after hospitalization. The project is targeted at patients in need of joint care by physicians and nursing services. To reach the above mentioned goals the project aims at improving communication and coordination between physicians, nursing personnel and hospitals. It is intended to extend treatment possibilities in the patient's homes thereby reducing rates of hospitalization as well as re-hospitalization.
8.) "Heart & Life" - Hypertension training
This project is targeted at patients suffering of arterial hypertension. Its goal is the provision of area-wide training programs for patients intended at enhancing their knowledge about their condition as well increasing their ability of active participation in treatment. The teaching method, which has been developed, used and evaluated in Germany has proven to be effective.
The project's second goal is the reduction of cardiovascular complication by improving hypertension therapy, which should result in a long-term reduction of demand for medical services related to cardiovascular diseases. In a first step physicians will undergo special training. In a second step these physicians will in turn train and instruct patients thereby ensuring the quality of patient training.
The project is jointly operated by the province of Styria, the regional sickness fund, the Styrian doctors chamber, basically all Styrian hospitals, Johanneum Research and the Association of Austrian Diabetes Consultants.
The Health Platform of Salzburg decided on two "reform pool" projects in April 2007. The projects deal with:
1.) Preoperative diagnostics
The aim of this project is to prevent needless examinations (e.g. needless blood collection or x-rays) before surgeries. As a result patients will have more time and less discomfort. Potential medical risks (concerning e.g. the cardiovascular system) are to be detected at an early pre-operative stage helping to minimize complications associated with surgery. The project is supported by the federal state, social health insurance, federal state hospitals of Salzburg and the doctors chamber of Salzburg.
2) Disease Management Program (DMP): "Therapie aktiv - Diabetes im Griff"
This project's goal is to establish a Disease Management Program (DMP) in Salzburg for patients with Diabetes Mellitus Type 2. It is possible to join the program in July 2007.
|Medienpräsenz||sehr gering||sehr hoch|
This policy is rather innovative as it aims at breaking down "silos" in care provision in Austria. Even though all actors and stakeholders share consensus about the need to promote coordination and cooperation across "silo borders", the impact of this policy will depend on the willingness of regional actors to promote better integration. If cooperations prove to be successful and stakeholders share common values regarding the improvement of care, the systemic impact is likely to be rather fundamental. However, the degree of implementation varies across federal states. While Lower Austria and Upper Austria seem to be very active in this area, Vorarlberg and Salzburg have not put much emphasis on developing programs. Vienna has also not progressed far but it seems that decisons will be taken soon.
Overall it will be necessary to monitor these initiatives to identify success factors or to better understand impediments to improved coordination and cooperation.
As in many countries these programs reflect efforts to improve care for the chronically ill and to ensure access. Even though many of these approaches have system specific features they are commonly used in many other countries; thus they are transferable to some degree.
|Implemented in this survey?|
The president of the Austrian Doctors Chamber claims that the current "reform pool" projects are not sufficient for dealing with the major challenges the Austrian health care system is facing. In addition he claims that in most federal states the "reform pool" projects are still in an early phase or in discussion - except in Lower Austria, where most projects started already in 2006.
The president of the Carinthian Doctors Chamber embraced the reform pool project "Improved access to speech therapists" as a positive step in the right direction and as an important contribution for multidisciplinary practice in the health care system. However, he criticised the lack of support of truly innovative projects, e.g. projects concerning the improvement of medical stand-by duty, or the formation of multi-physician-centers.
The chairman of the Curia of employed physicians criticised that some "reform pool" projects primarily focus on hospitals and that consulting firms will benefit rather than actors in the health care system per se. In addition, he stressed that the incentives of the current financing mechanism are not sufficient to improve efficiency and effectiveness by shifting patients from inpatient care to private practices. According to him there are still too many acute care beds and too few long-term care beds.
Ministry of Health
In December 2006, the former minister of health acknowledged that the funds earmarked for "reform pool" projects might not be sufficient. Currently 2% of the public health care funds have been allocated to "reform pool" projects. In spite of this the current projects should still have an impact. She pointed out that most projects are still in a pilot phase. Innovative projects should be developed and realized stepwise, giving the various stakeholders an opportunity to place ideas and launch projects.
The former chief of staff in the Ministry of Health postulated the need of alternatives in the outpatient sector such as multidisciplinary specialist-centers. "Reform pool" projects should primarily support the formation of health-centers in private practices. According to him this strategy is not fully supported by some of the projects.
The head of the Health Policy and Prevention department of the Viennese Sickness Fund claims that the main problem concerning "reform pool" projects is a lack of funds. As no additional funds have been made available current money would have to be shifted. "In some cases a "reform pool" project is only a continuance of already existing approaches without bringing a new drive in the system." She further criticised that the actors involved are hesitant when it comes to cooperation. The main problem is claimed to be a lack of exchange of data. Sharing data would be an indispensable basis for better coordination and integration of care.
|Government||sehr unterstützend||stark dagegen|
|Health insurance funds||sehr unterstützend||stark dagegen|
|Hospitals||sehr unterstützend||stark dagegen|
|Physicians||sehr unterstützend||stark dagegen|
|Patients||sehr unterstützend||stark dagegen|
|Health care experts||sehr unterstützend||stark dagegen|
|Health insurance funds||sehr groß||kein|
|Health care experts||sehr groß||kein|
According to federal guidelines, an evaluation concept has to be compiled for each project. The evaluation has to include/describe:
If necessary, an independent external monitoring can be organised. After completion of the project, an evaluation report has to be written.
Example of an Evaluation:
The case of Diabetic Care (DIA) Upper Austria
The Institute of Health Planning of Upper Austria will conduct this evaluation. Central element of quality assurance will be a so-called "documentation pass" which documents treatment steps and results. Once a year the most important medical parameters have to be reported to the regional Sickness Fund of Upper Austria. Physicians have to fulfil education requirements for the treatment of diabetes patients consisting of a basic module and an additional "train the trainer" seminar for physicians who offer patient trainings.
Continuous monitoring will be conducted by the regional Sickness Fund of Upper Austria. This includes the registration of patients, the pseudo-anonymisation of evaluation data, forwarding the data to the Institute of Health Planning, continuous monitoring of the frequency of periodic medical care. A cost evaluation will also be conducted.
Furthermore, quality indicators are to be defined, e.g. parameters on the basis of documentation data (such as blood pressure, weight, LDL etc.), patient satisfaction, physician satisfaction and development of costs.
Environment and risk analysis concerning patients' acceptance, time management problems for full-time physicians in private practices and area-wide supply of patients training programs are also planned.
First results of this evaluation suggest that quality of care and patient satisfaction has improved. In the context of a case control studies quality and cost indicators were monitored. Compared with the control group 780 Euros per year could be saved mainly by reducing hospitalisation of patients participating in the program (Institut fuer Gesundheitsplanung 2005).
While there is some variation in the scope and the content of these programs across federal states they all aim at improving system performance by enhancing quality of care and improving cost efficiency. This will be largely achieved by better adherence to guidelines, e.g. disease managment programs, and avoidance of hospitalisation, e.g. reduction of re-admissions or duplications of interventions. Programs launched often target chronic diseases, e.g. diabetes, coronary heart disease, or improve access, e.g access to speech therapists.
An intangible benefit of these initiatives is that cooperation and exchange across providers and between payers is enhanced. This facilitates patient-centered care. It further stimulates desirable investments in prevention on behalf sickness.
A system-wide impact of these programs will largely depend on success factors identified by evaluations. However, it is currently premature to assess which factors best facilitate patient-centred care. Furthermore, evaluation designs may not be coherent across federal states. Thus, transferability of results may be limited. Furthermore, more funds are probably needed to restructure care provision across sectors, e.g. the creation of multidisciplinary health centers. These are probably best suited to provide appropriate care outside hospitals and better coordinated across sectors.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
We believe that the quality of service provison may improve because providers are required to adhere to medical guidelines. Many programs measure patient empowerment which may enhance satisfaction, an important dimension of quality.
Equity and cost efficiency may well improve but probably not in the short-term. Currently the room for manoeuvering patients followed by funds, e.g. the "reform pool" funds, is probably limited. Further developments in this area , e.g. the Austrian-wide health service planning and more investments are needed to improve patient-centered care and to show a viable impact on equity and cost efficiency.
Health State Agencies in Vienna, Burgenland, Lower Austria, Upper Austria, Styria, Carinthia, Tyrol and Vorarlberg
Bundesministerium für Gesundheit und Frauen (BMGF): Leitlinien für den Kooperationsbereich (Reformpool), Juli 2005.
"Langfristige Planung statt Reförmchen", Ärzte Woche, 20. Jahrgang Nr. 50, 2006
"Reformpool-Geld für Logopädie", Ärzte Woche, 21. Jahrgang Nr. 4, 2007
"Gibt's Alternativen zu den Amulanzen?", Ärzte Woche, 20. Jahrgang Nr. 44, 2006
"Hürdenlauf Integrierte Versorgung", Ärztewoche, 21. Jahrgang Nr. 9, 2007
"Newsletter, Institut fuer Gesundheitsplanung, Linz. Ausgabe 2/2005 http://www.gesundheitsplanung.at/documents/IGP_Newsletter_0503_000.pdf
|Integration of care after the 2005 health reform|
Process Stages: Umsetzung
Hofmarcher, Maria M., Gerald Röhrling and Dominik Walch