06 Abr Spain: Reinventing chronic care management for the elderly

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Brookings / Mark B. McClellan and Elisa Tarazona Gines

06/04/2015

 

Ribera Salud Hospital System l Valencia, Spain

Provider type: Public-private municipal health system
Program name: Complex Care Plan

Part 1: Background

Like many developing countries, Spain’s diverse population of over 47 million has a high burden of chronic disease and is aging. The World Health Organization (WHO) estimates that over 90 percent of all deaths in Spain can be attributed to chronic, non-communicable diseases (NCDs), and 17 percent of the population is over the age of 75. All Spanish citizens are guaranteed access to health care services through a universal health insurance system, which offers coverage for preventive care, disease management, hospital care, and long-term care. Public health care services are overseen nationally by the Spanish National Health System (NHS), which helps prevent, manage, and treat complex diseases while offering cost-effective care. Public health care is funded through taxes, and authority is in the hands of the regional governments. The federal government plays a coordination role. Health care represents approximately9.6 percent of GDP (7.1 percent public sector and 2.5 percent private sector).

About Ribera Salud

In the autonomous Spanish region of Valencia, Ribera Salud, a private integrated health care provider, has contracted with the government of Valencia to manage the provision of public health care services in over two dozen municipal departments of health in the region. The Ribera Salud health system is a public-private partnership that departs from Spain’s traditional health care system of public ownership, employment, delivery, and financial control. The model was developed as a “design, build, operate, and maintain” public-private partnership. This means that while the government continues to own the facilities, Ribera Salud takes responsibility for managing the delivery of services, employs many of the physicians involved in care, and provides property maintenance for all hospitals and primary care centers in the network. Some of the primary care centers include short-stay units for short duration inpatient care. Ribera Salud receives a capitated payment and is accountable for quality and cost of care for its population.

Approximately 720,000 patients receive care from hospitals and primary care centers in the Ribera Salud network. This case study focuses on Ribera Salud’s Complex Care Plan (Plan de Atención al Paciente Crónico), which integrates medical care and social services for elderly patients with more than two chronic diseases. Today, over 4,500 individuals are enrolled in the program across two municipalities: Torrevieja and Elche-Vinalopó.

Torrevieja has the highest concentration of elderly Spanish and foreign retirees in the country– over 25 percent of the population in Torrevieja is above age 65. In 2012, Ribera Salud launched the Complex Care Plan signaling a response to the specific needs of patients with two or more chronic diseases, many of whom require integrated care across a health care team. Ribera Salud holds a contract with a single payer (the regional government of Valencia) and receives a single non-adjusted capitated fee per person. The main goals of the whole system are to keep the entire population as healthy as possible and achieve the best value for care and the best use of hospital resources.

The Complex Care Plan is an initiative that responds to this strategic population health management goal for a segment of Ribera Salud’s elderly patients. The Complex Care Plan coordinates care across multidisciplinary teams that may include physicians, nurses, home health aides, mental health professionals, paramedics, social workers, the patient’s home caregiver, and the patient. This integrated approach to disease management provides better care for the patient, and provides specialized attention across primary, secondary or home-based care. It has also demonstrated significant cost savings, particularly through decreased emergency room use. To date, the program has resulted in significant reductions in unnecessary and avoidable hospital admissions and readmissions (see more results in Part 3).

Ribera Salud has faced several challenges and learned many lessons throughout their efforts, including the importance of cultivating a strong team-based working environment, integrating data systems, using patient-centered indicators, focusing on maintaining and improving patients health, and enhancing provider satisfaction. These are explained in more detail in Part 4.

Ribera Salud’s Payment Model

The Spanish NHS allocates a fixed capitation payment of 639 € (~ $690) per person per year to cover all primary and hospital care services for any person in the defined geographic region. This payment is not risk-adjusted and excludes outpatient pharmacy prescriptions, domiciliary oxygen, sanitary transportation, or prosthesis. The patient does not pay any copay or out-of-pocket costs for any of the covered services. In Spain patients are free to seek care at any time and in any place nationwide, that is, patients do not face limitations or penalties when seeking health services in other municipalities or health networks.

Ribera Salud is eligible for incentives to keep patients within its regional network. For instance, if a patient attributed to Ribera Salud seeks care at an out-of-network public medical facility Ribera Salud must pay the other network for the patient’s care at a regionally set price. The regionally set price is often higher than the internal price Ribera Salud has set, which means that they lose money when patients seek care outside the network. Moreover, the outside providers are not part of Ribera Salud’s care coordination and improvement activities, which may also lead to higher costs. Therefore, Ribera Salud has a built-in financial mechanism to provide efficient and quality care that keeps attributed patients within their network.The payment model for Ribera Salud is an at-risk corridor in which Ribera Salud can keep all savings up to 7.5 percent of their capitated payment. Any additional profit returns to the Valencia government. Ribera Salud is responsible for any excess costs above the capitated payment of 639 € per person per year.

Part 2: Innovations in Care

The Complex Care Plan’s goal is to transform care delivery by focusing on evidence-based clinical pathways and patient-centered outcomes. The structure supports team-based care by providing financial incentives based on a team’s ability to meet quality benchmarks. Care teams are multidisciplinary and provide coordinated medical and social care in both settings. Non-clinical team members include social workers, mental health professionals, home aides, caregivers, and the patient.

The Complex Care Plan’s pillars for successful chronic and complex care include: models of care are based on the needs of people at all stages of life, address all levels of chronic conditions, proactively involve all care providers in the management of complex patients, emphasize coordination of primary and specialty care by including an internal medicine specialist in each health center. They also empower nurses to increase their involvement in chronic care services, identify high quality offices as “best therapeutic” places of care, follow health promotion and disease prevention as the guiding principles of care, integrate all the different levels of care including social services and public health, promote and use technical resources, and endorse patients and caregivers as active participants in the care process.

Part 3: Characterization of Accountable Care

This case study uses the five pillars of the Center for Health Policy’s Global Accountable Care Framework to describe the Complex Care Plan. The Framework pillars include: population, performance measures, continuous improvement, payments and incentives, and care coordination and transformation (Figure 1).

Figure 1: The Five Pillars of Accountable Care and Key Innovations at Ribera Salud



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