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The rising burden of chronic illness, in particular the rapid increase in the number of people withmultiple health problems, is a challenge to health systems globally. Associated premature mortalityand reduced physical functioning, along with higher use of health services and related costs, areamong the key concerns faced by policy-makers and practitioners.

There is a clear need to redesign delivery systems in order to better meet the needs created bychronic conditions, moving from the traditional, acute and episodic model of care to one that bettercoordinates professionals and institutions and actively engages service users and their carers.Many countries have begun this process but it has been difficult to reach conclusions about thebest approach to take: care models are highly context-dependent and scientifically rigorous evaluations have been lacking.

Assessing chronic disease management in European health systems explores some of the key issues, ranging from interpreting the evidence base to assessing the policy context for, and approaches to, chronic disease management across Europe. Drawing on 12 detailed country reports(available in a second, online volume), the study provides insights into the range of care modelsand the people involved in delivering these; payment mechanisms and service user access; andchallenges faced by countries in the implementation and evaluation of these novel approaches.

This book builds on the findings of the DISMEVAL project (Developing and validating DISease Management EVALuation methods for European health care systems), led by RAND Europe andfunded under the European Union’s (EU) Seventh Framework Programme (FP7) (Agreement no. 223277).

The editors

Ellen Nolte, Hub Cordinator, European Observatory on Health Systems and Policies.

Cécile Knai, Senior Lecturer, London School of Hygiene & Tropical Medicine.

Richard B. Saltman, Professor of Health Policy and Management at the Rollins School of PublicHealth of Emory University in Atlanta and Associate Head of Research Policy at the EuropeanObservatory on Health Systems and Policies.

Observatory Studies Series No. 37

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Concepts and approaches

Assessing chronic disease management in European health systems

Edited by

Ellen Nolte

Cécile Knai

Richard B. Saltman

Cover_WHO_nr37_bis_Mise en page 1 5/02/15 15:39

The European Observatory on Health Systems and Policies supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in Europe. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues.

The European Observatory on Health Systems and Policies is a partnership, hosted by the WHO Regional Office for Europe, which includes the Governments of Austria, Belgium, Finland, Ireland, Norway, Slovenia, Sweden, the United Kingdom and the Veneto Region of Italy; the European Commission; the World Bank; UNCAM (French National Union of Health Insurance Funds); the London School of Economics and Political Science; and the London School of Hygiene & Tropical Medicine.



Edited by

Ellen NolteCécile KnaiRichard B. Saltman

on Health Systems and Policies

European

a partnership hosted by WHO

iv Assessing chronic disease management in European health systems

Keywords:CHRONIC DISEASEDELIVERY OF HEALTH CARE, INTEGRATEDHEALTH CARE SYSTEMSHEALTH POLICYPUBLIC HEALTH

© World Health Organization 2014 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies)

All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full.

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All reasonable precautions have been taken by the European Observatory on Health Systems and Policies to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the European Observatory on Health Systems and Policies be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the European Observatory on Health Systems and Policies or any of its partners.

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Contents

Preface vii

Acknowledgement ix

List of tables and boxes xi

List of abbreviations xiii

Volume I contributors xv

1 Introduction 1 1.1 Background 1 1.2 Approach to this book 3 1.2.1 Conceptualizing chronic disease and chronic disease management 4 1.2.2 Countries included in the review 7 1.3 About this book 7

2 What we know: a brief review of the evidence of approaches to chronic care 9 2.1Managingcareforpeoplewithchronicconditions:conceptsanddefinitions 9 2.1.1 Disease management 10 2.1.2 Integrated care 11 2.2 What we do know: a review of the evidence base on approaches to caring for people with chronic conditions 12 2.2.1 Disease management 12 2.2.2 Integrated care 15 2.2.3 Economic impacts of disease management or integrated care 18 2.3 What we need to know: limitations of the existing evidence base 19 2.4 Conclusions 21

3 Approaches to chronic disease management in Europe 23 3.1 Key features of the health care systems in 12 European countries 23 3.2 The policy context for chronic care in Europe 25 3.3 Overview of approaches to chronic disease management in 12 European countries 30 3.4 Financing, distribution and uptake of approaches to chronic disease management 42 3.5 Components of chronic disease management 55 3.6 Conclusions 70 3.6.1 The majority of approaches tend to focus on populations with definedconditions 70

vi Assessing chronic disease management in European health systems

3.6.2 There is a trend towards strengthening the role of nurses in care delivery and coordination 71 3.6.3 Approaches that seek to reduce barriers between sectors remain less common 71 3.6.4Theimplementationofapproachesfrequentlyinvolvesfinancial incentives 72 3.6.5 Levels of patient and clinician support vary 72

4 Looking ahead 73 4.1 Learning from existing approaches 74 4.1.1 Incorporating the patient perspective 80 4.2 Providing the (regulatory) context to enable innovation 83References 85

Preface

This book comprises two volumes and builds on the findings of the DISMEVAL project (Developing and validating DISease Management EVALuation methods for European health care systems), funded under the European Union’s (EU) Seventh Framework Programme (FP7) (Agreement no. 223277). DISMEVAL was a three-year European collaborative project conducted between 2009 and 2011. It contributed to developing new research methods and generating the evidence base to inform decision-making in the field of chronic disease management evaluation (www.dismeval.eu).

In this book, we report on the findings of the project’s first phase, capturing the diverse range of contexts in which new approaches to chronic care are being implemented and evaluating the outcomes of these initiatives using an explicit comparative approach and a unified assessment framework. In this first volume, we describe the range of approaches to chronic care adopted in 12 European countries. By reflecting on the facilitators and barriers to implementation, we aim to provide policy-makers and practitioners with a portfolio of options to advance chronic care approaches in a given policy context.

In volume II (available online at http://www.euro.who.int/en/about-us/partners/observatory/studies), we present detailed overviews of each of the 12 countries reviewed for this work and which informed the overview presented in the first volume of the book.

Ellen NolteEuropean Observatory on Health Systems and Policies

Cécile KnaiLondon School of Hygiene & Tropical Medicine

Richard B. SaltmanEmory University in Atlanta

Acknowledgements

Led by RAND Europe, the DISMEVAL project brought together 10 partners in seven EU countries and a range of associates in five additional countries. The following members of and associates to this project contributed directly or indirectly to this book through the collection and synthesis of information and data, the drafting of country reports as presented in volume II of the book, and the review of chapters (affiliation at the time of the DISMEVAL project):

RAND Europe, Cambridge, UK: Laura Brereton, Annalijn Conklin, Saba Hinrichs, Ellen Nolte, Janice Pedersen, Martin Roland (special adviser to RAND Europe)

London School of Hygiene & Tropical Medicine, London, UK: Cécile Knai

Paracelsus Medizinische Privatuniversität, Salzburg, Austria: Maria Flamm, Andreas Sönnichsen

Københavns Universitet, Copenhagen, Denmark: Anne Frølich, Ramune Jacobsen

Université Paris Est Créteil Val de Marne, Paris, France: Matthias Brunn, Benjamin Cadier, Karine Chevreul, Isabelle Durand-Zaleski

Goethe Universität, Frankfurt am Main, Germany: Antje Erler, Birgit Fullerton

Universiteit Maastricht, the Netherlands: Arianne M.J. Elissen, Inge G.P. Duimel-Peeters, Cor Spreeuwenberg, Hubertus J.M. Vrijhoef

Centre Léon Bérard Lyon et Rhône-Alpes, Lyon, France: Fadila Farsi, Hélène Labrosse

Instituto de Salud Carlos III, Madrid, Spain: Zuleika Saz Parkinson, Antonio Sarria Santamera

AQUA Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, Göttingen, Germany: Robert Krohn, Boris Pöhlmann

In addition, the following experts contributed reports on individual countries not covered by the DISMEVAL partnership:

Estonia: Taavi Lai

x Assessing chronic disease management in European health systems

Hungary: Márton Csere, Peter GaalItaly: Antonio Giulio de Belvis, Walter Ricciardi, Maria Lucia Specchia, TD Luca ValerioLatvia: Maris TaubeLithuania: Liubove Murauskiene, Maria VeniuteSwitzerland: Isabelle Peytremann-Bridevaux, Bernard Burnand, Ignazio Cassis

Further, we would like to thank Jonathan North and Caroline White, as well as Peter Powell (typesetting) and Sonia Cutler (editing).

List of tables and boxes

Tables

Table 1.1 Differentiating acute and chronic conditions 4

Table 2.1 Review of reviews: evidence of the effect of disease management programmes 13

Table 3.1 Principlesofhealthcarefinancingin12Europeancountries 24

Table 3.2 Selected features of health care systems in 12 European countries 26

Table 3.3 Overview of approaches to chronic disease management or their equivalent in 12 European countries 33

Table 3.4 Financing, distribution and uptake of approaches to chronic disease management or their equivalent in 12 European countries 43

Table 3.5 Components of chronic disease management used in 12 European countries 57

Boxes

Box 1.1 Approaches to chronic disease management or chronic care: definitionofterms 5

Box 4.1 ReportedbarrierstoevaluationinfiveEuropeancountries 79

Box 4.2 Balancing the gap between policy intent and actual implementation: evidence from the DISMEVAL project 84

List of abbreviations

AIDS Acquired immunodeficiency syndromeASALEE Health Action by Teams of Self-employed Health Professionals (France)ASL Local Health Authority (Italy)AWBZ Exceptional Medical Expenses Act (Netherlands)BRASS Blaylock Risk Assessment Screening ScoreCAPI Contracts for Improved Individual Practice (France)CHD Coronary heart diseaseCHF Swiss francCCM Chronic Care ModelCCP Care coordination pilotCMP Care management programmeCNAM Caisse Nationale d’Assurance Maladie (France)COPA Coordinating Care for Older People (France)COPD Chronic obstructive pulmonary diseaseCVD Cardiovascular diseaseDBC Diagnosis and treatment combinations (Netherlands)DIEP Diabetes Interactive Education ProgrammeDDKM Danish Quality Model (Denmark)DKK Danish kroneDMP Disease management programmeDRG Diagnosis-related groupEBM Uniform Assessment Scale (Germany)EEP Evaluation of professional practice (France)EHIF Estonian Health Insurance FundEU European UnionFFS Fee-for-serviceFIQCS Intervention Fund for Quality and Care Coordination (France)GDP Gross domestic productGP General practitionerHAS National Authority for Health (France)HMO Health maintenance organizationICC Integrated care contractICP Integrated care pilotIGEA Diabetes Integration, Management and Assistance (Italy)IHD Ischaemic heart diseaseLKF Performance-based financing (Austria)MIGAC Missions d’intérêt général et à l’aide à la contractualisation (France)

xiv Assessing chronic disease management in European health systems

NIHFA National Health Insurance Fund Administration (Hungary) ÖDG Austrian Society of DiabetesOOP Out-of-pocketPbR Payment by result (England)PCT Primary Care Trust (England)PHC Primary health carePOPP Partnership for Older People Project (England)PPP Purchasing power parityPPS Personalized care programme (France)QALY Quality-adjusted life yearsQOF Quality and Outcomes Framework (England)RCP Multidisciplinary team meeting (France)ROSP Payment based on specific public health objectives (France)RSA Risk structure compensation scheme (Germany)SHI Statutory health insuranceSIKS Integrated Effort for People Living with Chronic Disease (Denmark)SSI State Serum Institute (Denmark)SSN National Health Service (Italy)URCAM Regional Unions of Insurance Funds (France)VerAH Care assistants in family practice (Germany)VHI Voluntary health insuranceWMO Social Support Act (Netherlands)ZiO Care in Development (Netherlands)

Volume I contributors

Cécile Knai is Senior Lecturer, Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.

Ellen Nolte was the lead author and editor of the Volume. She is Hub Coordinator at the European Observatory on Health Systems and Policies, London School of Economics and Political Science, and London School of Hygiene & Tropical Medicine, London, UK.

Emma Pitchforth is Research Leader in the Health and Healthcare Research Programme at RAND Europe, Cambridge, UK.

Richard B. Saltman is Professor of Health Policy and Management at the Rollins School of Public Health of Emory University in Atlanta, Georgia, USA. He is also Associate Head of Research Policy at the European Observatory on Health Systems and Policies.

Chapter 1

IntroductionEllen Nolte, Cécile Knai

1.1 Background

Responding to the burden of chronic disease presents challenges for all health systems. As populations age and advances in health care allow those with once fatal conditions to survive, the prevalence of chronic conditions is rising in many countries (Yach et al., 2004). In the European Union (EU), in 2006, from 20 to over 40% of the population aged 15 years and over reported a long-standing health problem and one in four received long-term medical treatment (TNS Opinion & Social, 2007). Other studies have found the prevalence of common chronic disorders was found to be around 50% among adults aged 18 and over in seven high-income countries, including Germany, the Netherlands and the UK (Schoen et al., 2007).

Although the rising burden of chronic disease is driven, in part, by population ageing it is important to recognize that such conditions are not limited to the older population. Thus, increasing numbers of children and young people are developing some form of chronic health problem (Barnett et al., 2012; Van Cleave, Gortmaker & Perrin, 2010), with over 80% of premature mortality estimated to be attributable to noncommunicable diseases in Europe (Institute for Health Metrics and Evaluation, 2013a).

Assessing the precise level, distribution and nature of the chronic disease burden in Europe remains a challenge (Pomerleau, Knai & Nolte, 2008); yet, it is clear that chronic diseases are important, greatly impacting on the years of life lived in good health. In high-income countries, mental disorders (for example, depression and anxiety disorder), musculoskeletal disorders (for example, lower-back pain), chronic obstructive pulmonary disease (COPD) or asthma, and diabetes, are among the leading causes of chronic disability (Institute for Health Metrics and Evaluation, 2013b), with diabetes projected to rise further in importance during the next two decades, especially against the background

2 Assessing chronic disease management in European health systems

of increasing levels of overweight and obesity (Danaei et al., 2013; Finucane et al., 2011).

The implications for health systems and society as a whole are considerable. Chronic diseases pose a sizeable burden for national economies, with associated costs estimated at up to 7% of a country’s gross domestic product (Suhrcke et al., 2006). Societal costs arise partly as a result of direct health care costs, including from health care use, medication and potentially costly interventions, with additional indirect costs deriving from, for example, increased absenteeism, and reduced productivity at work (Suhrcke, Fahey & McKee, 2008). These challenges add to the complexity facing health systems, which require effective measures to prevent disease through reducing the major chronic disease risk factors and addressing influences that drive exposure (Novotny, 2008), while also providing services to meet the requirements caused by chronic health problems, thereby ensuring that people with established disease can participate in society.

The goals of care for those with chronic conditions are not to cure but to enhance functional status, minimize distressing symptoms, prolong life through secondary prevention and enhance the quality of life (Grumbach, 2003). These goals are unlikely accomplished through the traditional acute, episodic model of care, which tends to see the patient as passive recipient of care and where treatment aims at return to normal (Holman & Lorig, 2000). In particular, where people have multiple health problems, creating a range of diverse and sometimes contradictory needs, the conventional care model is insufficient (Piette, Richardson & Valenstein, 2004). Instead, what is needed is a delivery model that involves coordinated inputs from a wide range of health professionals over an extended period of time and that places patients at the centre as co-producers of care to optimize health outcomes (Nolte & McKee, 2008a).

However, service delivery has developed in ways that have tended to fragment care, both within and between sectors, for example, through structural and financial barriers at the interface between primary and secondary care and between health and social care, distinct organizational and professional cultures and differences in terms of governance and accountability (Glasby, Dickinson & Peck, 2006). There is thus a need for new service delivery models that are characterized by collaboration and cooperation among professions and institutions that have traditionally worked separately.

The growing recognition of this need is causing many countries to explore new approaches to health care delivery that can bridge the boundaries between professions, providers and institutions and therefore provide appropriate

3Introduction

support to patients with long-standing health problems. We have previously shown how countries vary in their attempts to do so, with many implementing some form of (chronic) disease management although the nature and scope of related approaches differ (Nolte, Knai & McKee, 2008). We have found that the strategies that are being implemented tend to reflect the characteristics of individual health systems with regard to the relationships between, and the responsibilities of, different stakeholders in the regulation, funding and delivery of health care. In particular, there is a suggestion that those health systems in which patients have traditionally chosen their provider without formal enrolment, paying for services episodically using fee-for-service as the predominant method of reimbursement, may face the greatest challenges in adapting towards providing effective chronic care (Busse & Mays, 2008).

However, there is a need to develop this evidence base further, using an explicit comparative approach and a unified framework for assessment to better understand the diverse range of contexts in which new approaches to chronic care are being implemented, and to evaluate the outcomes of these initiatives. There is also a need to better understand the content of these new models, which are frequently applied from different disciplinary and professional perspectives and are associated with different goals. In this book, we aim to contribute to this process by identifying the range of approaches to chronic care adopted in 12 European countries. By reflecting on facilitators and barriers to implementation we aim to provide policy-makers and practitioners with a portfolio of options to advance chronic care approaches in a given policy context.

1.2 Approach to this book

We build on earlier work which examined the health system context for chronic disease (Nolte & McKee, 2008a), assessed the evidence base for chronic care (Nolte & McKee, 2008b) and reviewed the experience in eight countries in Europe and beyond (Nolte, Knai & McKee, 2008). It seeks to extend this earlier work by drawing on information on approaches to (chronic) disease management and evaluation strategies in a range of European countries that was collected within the DISMEVAL (Developing and validating DISease Management EVALuation methods for European health care systems) project. DISMEVAL was a three-year European collaborative project, conducted between 2009 and 2011, which aimed to contribute to developing new research methods and to generating the evidence base to inform decision-making in the field of chronic disease management evaluation. It was funded under the European Commission’s Seventh Framework Programme.


1.2.1 Conceptualizing chronic disease and chronic disease management

Chronic conditions or chronic health problems have been described in different ways (Nolte, McKee & Knai, 2008); it is therefore important to briefly set out the terminology we will be using throughout this book. We adopted a general definition, which is principally based on the effects and associated care needs, rather than the cause of the condition in question (Unwin, Epping Jordan & Bonita, 2004). We distinguished acute conditions, which are potentially curable within a short period of time, from chronic conditions, which are either incurable or require prolonged treatment and care, and for which there is a chance of developing intercurrent episodes or acute illnesses associated with the chronic condition (Holman & Lorig, 2000). This differentiation is summarized in Table 1.1.

Table 1.1 Differentiating acute and chronic conditions

Acute condition Chronic condition

Onset Abrupt Generally gradual and often subtle

Duration Limited Lengthyorindefinite

Cause Typically single cause Typically multiple causes with changes over time

Diagnosis and prognosis Usually accurate Frequently uncertain

Technological intervention Usually effective Often indecisive, adverse effects common

Outcome Cure possible No cure

Uncertainty Minimal Pervasive

Knowledge Professionals knowledgeable, patients inexperienced

Professionals and patients have complementary knowledge and experiences

Sources: adapted from Department of Health (2004), based on Holman & Lorig (2000).

This definition includes a range of common, long-term health problems such as diabetes, heart disease or COPD, and progressive mental and neurological disorders. It also includes disabilities and impairments not defined as diseases, such as musculoskeletal disorders, and selected communicable diseases such as human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (Nolte & McKee 2008a). We also consider cancer, as in some settings approaches to chronic disease management may also target certain cancer sites, for example, breast cancer disease management programmes in Germany or cancer networks in France (Nolte, Knai & McKee, 2008).

We restricted the scope of approaches reported in this book to the management of people with established chronic health problems although we also considered measures of secondary prevention targeted at people at high risk of developing a chronic disabling disease, such as vascular risk management. However, we

5Introduction

excluded measures of primary prevention or health promotion in the context of this work.

Although the DISMEVAL project focused on approaches that can be broadly subsumed under the heading of “disease management”, it is important to acknowledge that definitions of this concept vary widely (Krumholz et al., 2006; Nolte & McKee, 2008b). We discuss this variation in terminology, and its implications for deriving a robust evidence base, further in Chapter 2. At the outset, and for the purposes of the DISMEVAL project, we defined disease management as comprising the following components: (1) an integrated approach to care or coordination of care among providers, including physicians, hospitals, laboratories and pharmacies; (2) patient education; and (3) monitoring or collecting patients’ outcome data for the early detection of potential complications (Krumholz et al., 2006). However, we acknowledge that approaches that are being tested across Europe may not fully meet this definition. Our study sought to capture the range of models that use a subset of disease management interventions or are otherwise conceptualized while pursuing the same objective, that is, to improve the care for those with chronic health problems. We therefore included a wider range of approaches, which we considered as “chronic disease management” or chronic care. Box 1.1 provides an overview of the range of approaches reviewed in this study.

Box 1.1Approachestochronicdiseasemanagementorchroniccare:definitionofterms

Care pathway(s) (synonyms: clinical pathway; care map; integrated care pathway):

Task-oriented care plan(s) that specify essential steps in the care of patients with a

specificclinicalproblemanddescribethepatient’sexpectedclinicalcourse(Campbell

et al., 1998).

Case management: Intensive monitoring of a person with complex needs by a named

case manager – usually a (specialist) nurse – through the development of care or

treatment plans that are tailored to the needs of the individual patient who is at high risk

socially,financiallyandmedically(Krumholzetal.,2006).

Chronic care model (CCM): A conceptual framework that presents a structure

for organizing health care comprising of four key components: (1) self-management

support; (2) delivery system design; (3) decision support; and (4) clinical information

systems (Wagner et al., 1999).

Coordinated care (synonyms: care management): Development and implementation

of a therapeutic plan designed to integrate the efforts of medical and social service

providers, often involving designated individuals to manage provider collaboration.


Box 1.1 contd

Disease management (programme) (DMP):Definitionsofdiseasemanagement

(programmes) vary substantially. Common features are: (1) an integrated approach to

care/coordination of care among providers, including physicians, hospitals, laboratories

and pharmacies; (2) patient education; and (3) monitoring/collecting patient outcomes

data for the early detection of potential complications (Krumholz et al., 2006). DM

programmes do not normally involve general coordination of care. They also not

normallyincludepreventiveservicessuchasfluvaccination.

Integrated care: Types of collaboration, partnerships or networks between providers

of health and social care services that work together to meet the multidimensional

needs of an individual patient/client or a category of persons with similar needs/

problems (Kodner & Spreeuwenberg, 2002; Nies & Berman, 2004).

Managed discharge: Arrangements for the transfer of an individual from hospital to

an appropriate setting (primary care; community care) to ensure that any rehabilitation,

recuperationandcontinuinghealthandsocialcareneedsareidentifiedandmet.

Multidisciplinary team(s)/care: An “extension” of case management that also

normally involves the development of treatment plans tailored to the medical,

psychosocialandfinancialneedsofpatients.Itskeyfeatureistheuseofabroader

range of medical and social support personnel (including physicians, nurses,

pharmacists, dietitians, social workers and others) to facilitate transition from inpatient

acute care to long-term, outpatient management of chronic illness (Krumholz et al.,

2006)

Nurse-led clinic: A formalized and structured health care delivery arrangement in

whichanursewithadvancedcompetencetopractiseinaspecifichealthcarearea

(nursepractitioner,clinicalnursespecialist,specialistnurse)actsasthefirstpointof

contact of care. The nurse manages patients either independently or interdependently

with other members of a health care team in at least 80% of their work. The key

interventions are: nursing therapeutics, encompassing assessment and evaluation;

health teaching/counselling; treatment and procedures; and case management. (NB:

Nurse-led clinics are different from nurse-led care insofar as the former describe a

formalized and structured delivery arrangement, whereas the latter also includes other

arrangements, for example, case management, liaison nurses, discharge nurse, etc.)

(Wong & Chung, 2006).

Provider network(s): A group of providers bringing together different levels of care (for

example, health and social care or primary and secondary care).

Source: compiled by the authors

7Introduction

1.2.2 Countries included in the review

We selected 12 countries for review: Austria, Denmark, England, Estonia, France, Germany, Hungary, Italy, Latvia, Lithuania, the Netherlands and Switzerland (the only non-EU country). Five of these countries (Denmark, England, France, Germany and the Netherlands) were reviewed in previous work (Nolte, Knai & McKee, 2008), but as these have further developed existing approaches or have implemented new approaches, their experience can provide important insights into the factors that have made these developments possible (or indeed hindered further advancement).

The review was based on a structured template for the collection of data on approaches to chronic disease management in European systems, which was based on earlier work by Nolte, Knai and McKee (2008), and informed, to great degree, by the Chronic Care Model developed by Wagner and colleagues in the United States (Wagner, 1998). Data collection was undertaken by key informants in the countries under review. It was beyond the scope of this study to provide a comprehensive inventory of all approaches being implemented in a given country; key informants were asked to present a “sample” of approaches considered representative of a given health system in terms of the type and setting of delivery model, providers involved, key strategies employed and the population covered. Data presented here reflect information collected by the summer of 2011, with updates to early 2014 where necessary and appropriate. Country reports formed the basis of the systematic cross-country comparison presented in this book. Further detail on the data collection that informed country reports is provided in the accompanying volume to this book (Nolte & Knai, 2015).

1.3 About this book

We begin in Chapter 2 with a brief review of the peer-reviewed literature on chronic disease management. In Chapter 3, we report on the key observations from our survey of 12 European countries on approaches to chronic care. We conclude with Chapter 4, which provides a summary analysis of findings reported in earlier sections. We suggest that this book should be read in conjunction with a second volume, which presents detailed overviews of each of the 12 countries reviewed for this work and which informed the summary overview presented in this book (Nolte & Knai, 2015).

Chapter 2

What we know: a brief review of the evidence

of approaches to chronic care

Ellen Nolte, Emma Pitchforth

This chapter provides a brief overview of the evidence base for chronic care.1 Drawing on our earlier work (Nolte & McKee, 2008b; Nolte & Pitchforth, 2014), it summarizes the evidence on approaches to managing care for people with chronic conditions. It begins by briefly reflecting on concepts used in the context of chronic care, reviewing the commonalities and differences between terms such as disease management and integrated care. It then provides an overview of published evidence on the effectiveness of selected approaches to improving the care of people with chronic conditions. It concludes with a section outlining the major gaps in our understanding of effective approaches to chronic care.

2.1 Managing care for people with chronic conditions: concepts and definitions

One challenge to identifying effective approaches to managing care for people with chronic conditions remains the absence of common definitions of underlying concepts. There is a plethora of terminologies that have variously been described as integrated care, coordinated care, collaborative care, managed care, disease management, case management, patient-centred care, chronic (illness) care, continuity of care, and others (Nolte & McKee, 2008b). While these may differ conceptually, the boundaries between them are often unclear and terms are frequently used interchangeably (Kodner & Spreeuwenberg, 2002), 1 This chapter is based on a summary overview of ‘Best practice in chronic care’, which informed the 2013 International Symposium on Health Care Policy convened by the Commonwealth Fund, New York (unpublished).


reflecting the range of disciplines and professional perspectives involved, along with a diverse set of objectives around “chronic care” (Nolte & McKee, 2008b). This issue is not only of academic relevance but has important implications for practice. Empirical evidence of approaches that can be subsumed under the above terms is often difficult to compare because of a lack in clarity in defining and describing the approach being studied. It thus remains problematic to arrive at conclusions about the relative value of one approach versus another.

Take two common concepts that are frequently used in the context of managing chronic conditions, disease management and integrated care. We have previously argued that these two concepts may reflect two ends of a spectrum of approaches that, ultimately, aim to ensure cost-effective quality care for service users with varied needs (Nolte & McKee, 2008b). Disease management, by definition, traditionally targets patient groups with specific conditions, such as diabetes, while integrated care is typically aimed more broadly at people with complex needs that arise from multiple chronic conditions, coupled with increasing frailty at old age. However, with more recent definitions of disease management explicitly adopting a broader view towards a population-based approach that addresses multiple needs (Population Health Alliance, 2014; Geyman, 2007), boundaries are becoming increasingly blurred.

2.1.1 Disease management

Disease management was first described in the USA in the 1980s, with an initial focus on educational programmes to promote medication adherence and behaviour change among people with specific chronic conditions (Bodenheimer, 1999). From the mid-1990s, in parallel with an emerging body of evidence pointing to the potential for disease management to improve care quality and lead to cost savings, disease management strategies were adopted more widely across the private and public sector in the USA (Krumholz et al., 2006) and, more recently, in several European countries (Nolte & Hinrichs, 2012; Rijken et al., 2014) with related concepts also implemented in Australia (Glasgow et al., 2008). However, as noted in the introduction to this book, approaches vary widely in focus, scope of interventions and populations covered (Nolte & Hinrichs, 2012). In the USA, descriptions range from “discrete programs directed at reducing costs and improving outcomes for patients with particular conditions” (Rothman & Wagner, 2003:257) to “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (Population Health Alliance, 2014). This second, comprehensive definition by the US-based Population Health Alliance suggests a shift from a single-disease focus towards a whole person model that addresses the needs of patients with comorbidities and multiple conditions.

11What we know: a brief review of the evidence of approaches to chronic care

Yet, although authors have increasingly adopted this broader definition, as discussed further on in this chapter, variation in what is referred to as disease management has remained (Coleman et al., 2009; Lemmens, Nieboer & Huijsman, 2009; Pimouguet et al., 2011). Importantly, in many settings the focus continues to be on single diseases, albeit with some adjustment to also consider comorbidity (Fullerton, Nolte & Erler, 2011), and there remain concerns overall about the suitability of current approaches to disease management to address the complex needs of those with multiple disease processes (Aspin et al., 2010; Nolte et al., 2012a; Rijken et al., 2014).

2.1.2 Integrated care

In contrast to disease management, the concept of integrated care has traditionally been discussed in the health and social care fields, with reference to linking the cure and care sectors (Kodner & Spreeuwenberg, 2002; Leutz, 1999). The application of the concept of integrated care to health and social care is not, however, clear-cut and different conceptualizations have been put forward, emphasizing, for example, the health care perspective (Gröne & Garcia-Barbero, 2001), or interpreting integration in terms of financing and delivery functions in the context of managed care (Øvretveit, 1998; Shortell, Gillies & Anderson, 1994). The common denominator of integrated care concepts and approaches is their primary aim of improving outcomes for, traditionally, frail older people and other population groups with diverse and complex needs. The focus is on service users with multifaceted problems who require assistance with activities of daily living (Nolte & McKee, 2008b).

From this perspective, the notion of integrated care can be seen to be distinct from disease management. But, with recent conceptualizations of disease management that encompass collaborative care models and broader population groups as advocated by the Population Health Alliance (2014), and an interpretation of integrated care that is often limited to linkages within the health sector, the lines between the two concepts are increasingly difficult to draw. A review of systematic reviews by Ouwens et al. (2005) illustrates this issue. It sought to assess the effectiveness, definitions and components of integrated care programmes for chronically ill patients; however, of the systematic reviews considered, the majority were reviews of disease management programmes.

This latter point highlights the continued challenges associated with differentiating approaches in the field of chronic care. Based on these observations, we argue that concepts of integrated care and narrower, health-sector-specific perspectives of disease management share a common goal of improving outcomes for those with (complex) chronic health problems by overcoming issues of fragmentation through linkage of services of different


providers along the continuum of care (Nolte & McKee, 2008b). However, while concepts of integrated care frequently (aim to) link with the social care sector, disease management programmes are typically limited to linkages within the health care sector. Furthermore, as noted previously, disease management tends to remain restricted to single diseases.

2.2 What we do know: a review of the evidence base on approaches to caring for people with chronic conditions

This section presents a summary overview of key observations from recent rapid evidence reviews of disease management and of integrated care published elsewhere (Nolte, 2015; Nolte & Pitchforth, 2014). Both reviews focused on published systematic reviews and meta-analyses in the relevant field, building on the aforementioned work by Ouwens et al. (2005). The precise scope of our earlier work differed, but in both cases, we limited our search to studies published from 2004 onwards since the review by Ouwens and colleagues (2005) had covered systematic reviews and meta-analyses that had been published during 1996 through to May 2004. Detailed overviews of these reviews are available at Nolte (2015) and Nolte & Pitchforth (2014). Where appropriate, we complement this summary with more recent evidence not captured in our earlier reviews.

2.2.1 Disease management

Our review of the effectiveness of programmes broadly defined as disease management identified 15 eligible systematic reviews or meta-analyses published between January 2004 and October 2012 (Nolte, 2015). A summary of key findings is presented in Table 1.1.

The conditions most frequently considered in the reviews were depression (Neumeyer-Gromen et al., 2004; Thota et al., 2012), heart failure (Drewes et al., 2012; Göhler et al., 2006; Gonseth et al., 2004; Roccaforte et al., 2005), diabetes (Egginton et al., 2012; Knight et al., 2005; Pimouguet et al., 2011), COPD or asthma (Adams et al., 2007; Peytremann-Bridevaux et al., 2008; Lemmens, Nieboer & Huijsman, 2009), or a combination of these (de Bruin et al., 2011; Ofman et al., 2004; Tsai et al., 2005). Definitions of disease management varied among studies, although all adopted a fairly comprehensive conceptualization, drawing, for example, on the definition by Ellrodt et al. (1997:1687), which defines disease management as “an approach to patient care that coordinates medical resources for patients across the entire delivery system”. Others built on the CCM proposed by Wagner (1998), which


Table

2.1

Rev

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of r

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012)

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bet

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sign

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sign

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no

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evid

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considers six elements as essential for improving chronic illness care (see Box 1.1). Several reviews analysed primary studies that included a minimum of two discrete interventions considered beneficial for chronic illness care, such as patient self-management, provider feedback, structured follow-up or role redesign (Lemmens, Nieboer & Huijsman, 2009; Peytremann-Bridevaux et al., 2008; Pimouguet et al., 2011), or a variation of this conceptualization (Egginton et al., 2012; Göhler et al., 2006; Neumeyer-Gromen et al., 2004; Roccaforte et al., 2005). Typically, around half of primary studies covered by the reviews were set in the USA, followed by Australia, the United Kingdom, Canada, Sweden and the Netherlands. Two reviews focused on studies set in the USA only (Egginton et al., 2012; Neumeyer-Gromen et al., 2004).

Studies reported on a diverse set of outcomes, reflecting the condition being targeted. In brief, available reviews provided fairly consistent evidence of a positive impact of disease management interventions targeting those with depression. These demonstrated, for example, significant improvements in depression severity (Neumeyer-Gromen et al., 2004), as well as depression symptoms, patient adherence to treatment, response to treatment and satisfaction with care, among other outcomes (Thota et al., 2012). One meta-analysis of 102 experimental or quasi-experimental studies targeting 11 conditions found that disease management interventions for those with depression had the highest proportion of studies demonstrating substantial improvements in patient care (48% statistically significant) (Ofman et al., 2004).

A similar consistency was found for disease management interventions targeting heart failure. These showed, for example, statistically significant reductions in the frequency of disease-specific and all-cause readmissions of between 10 and 30% (Gonseth et al., 2004; Roccaforte et al., 2005), with some evidence of a reduction in all-cause mortality (Roccaforte et al., 2005; Göhler et al., 2006; Savard, Thompson & Clark, 2011; Drewes et al., 2012). There was also some evidence that programmes that had incorporated a multidisciplinary team approach had a stronger impact on outcome measures (Roccaforte et al., 2005; Göhler et al., 2006). However, Savard, Thompson and Clark (2011), in a meta-review of meta-analyses of heart failure disease management programmes found the quality of reviews to be moderate and very mixed across reviews, with studies not adequately taking account of programme complexity and heterogeneity.

Evidence for the impact of disease management on diabetes also tended to show beneficial effects overall, with significantly improved glycaemic control among diabetes disease management populations compared to usual care, although the overall clinical significance of observed improvements remains uncertain (Knight et al., 2005; Pimouguet et al., 2011; Egginton et al.; 2012). However,


there was evidence that disease management may be more effective for patients with poor glycaemic control (Pimouguet et al., 2011). The review by Knight et al. (2005) further showed that observed effects were larger for studies conducted in the USA, although the number of trials outside the USA considered in the review was small (Knight et al., 2005). Overall there was considerable variation across studies included in individual reviews in terms of intervention delivery methods, duration and populations, and such a variation was also observed in studies that examined the evidence base for disease management targeted at people with COPD or asthma. Among these, there was evidence of reduced health service use, such as hospitalizations, among those receiving disease management (Adams et al., 2007; Peytremann-Bridevaux et al., 2008), while impacts on clinical outcomes were mixed across reviews, with some evidence of a reduction in all-cause mortality among targeted patients (Peytremann-Bridevaux et al., 2008). This last review considered trial evidence from a range of countries, including Canada, the Netherlands, New Zealand, Spain, Sweden and the USA.

2.2.2 Integrated care

Our review of integrated care focused on the economic impacts of relevant approaches (Nolte & Pitchforth, 2014). We identified 19 systematic reviews and meta-analyses published between 2004 and 2012, although it is important to note that of the reviews included, none explicitly defined the term integrated care. Instead, the most commonly used strategies were described as case management (Chiu & Newcomer, 2007; Smith & Newton, 2007; Oeseburg et al., 2009; Pimouguet et al., 2010), collaborative care (Gilbody, Bower & Whitty, 2006; Brink-Huis, van Achterberg & Schoonhoven, 2008; van Steenbergen-Weijenburg et al., 2010), or a combination of these (Phillips et al., 2004; Langhorne et al., 2005; Shepperd et al., 2008; Steffen et al., 2009; Althaus et al., 2011; Smith et al., 2012; Tappenden et al., 2012), alongside notions such as seamless care (Simoens et al., 2011). Four reviews focused on disease management interventions that involved multicomponent approaches (Neumeyer-Gromen et al., 2004; Maciejewski, Chen & Au, 2009; Steuten et al., 2009; de Bruin et al., 2011). Of these, two were also considered in our review of disease management reported previously in this chapter; therefore, we do not report on these two reviews in this section (Neumeyer-Gromen et al., 2004; de Bruin et al., 2011).

Reviews considered a wide range of interventions or initiatives that targeted a diverse group of people or populations. Several studies focused on adults with specific chronic conditions including pain (Brink-Huis, van Achterberg & Schoonhoven, 2008), depression (Gilbody, Bower & Whitty, 2006; van


Steenbergen-Weijenburg et al., 2010), stroke (Langhorne et al., 2005), asthma (Maciejewski, Chen & Au, 2009), COPD (Steuten et al., 2009), or those with multimorbidity (Smith et al., 2012). Four reviews considered integrated care approaches for older people in the community considered to be frail (Oeseburg et al., 2009) or have long-term medical or social care needs (Tappenden et al., 2012), those with specific chronic conditions, such as heart failure (Phillips et al., 2004), or those who were to be discharged from hospital (Chiu & Newcomer, 2007). Three reviews focused on adults with dementia or memory loss (Pimouguet et al., 2010), those with severe mental health problems (Smith & Newton, 2007), or those who received mental health care services (Steffen et al., 2009), while the remainder addressed populations defined by patterns of health service use (Shepperd et al., 2008; Althaus et al., 2011; Simoens et al., 2011).

Initiatives frequently targeted the interface between hospitals and primary care or community services, most often in the context of discharge planning or care transition (Phillips et al., 2004; Langhorne et al., 2005; Chiu & Newcomer, 2007; Steffen et al., 2009; Althaus et al., 2011; Simoens et al., 2011). Several studies examined initiatives that sought to coordinate primary care and community services, often, although not always, involving medical specialists (Gilbody, Bower & Whitty, 2006; Brink-Huis, van Achterberg & Schoonhoven, 2008; van Steenbergen-Weijenburg et al., 2010; Smith et al., 2012) or extending further into social care services (Smith & Newton, 2007; Pimouguet et al., 2010; van Steenbergen-Weijenburg et al., 2010; Tappenden et al., 2012). The latter type of interventions tended to target older people with multiple care needs, those with dementia or with mental health problems. The definition of what constitutes community services or social care differed across the individual studies reviewed, making any generalization of the extent of integration across sectors difficult. This last point also reflects the differences in settings, with typically about half of primary studies considered by reviews set in the USA, followed by the United Kingdom, Australia, Canada, New Zealand, the Netherlands, Spain, Italy and Sweden.

Similar to studies of the effectiveness of disease management, reviews of the impacts of integrated care reported on a diverse set of outcomes that we attempt to summarize here. We should reiterate that our original review focused on the economic impacts of approaches considered as integrated care (Nolte & Pitchforth, 2014). Therefore, our review captured only a subset of relevant studies that included cost measures and that did not necessarily cover the broader range of outcomes. These limitations reflect our selection process rather than an absence of evidence; where appropriate we complement our discussion with evidence from systematic reviews not included in our initial review.


Categorizing reviews by type of integrated care strategy or approach, we found mixed evidence for the impact of case management. One review of case management in mental health, which focused on studies assessing assertive community treatment or intensive case management, reported some limited evidence of increased patient satisfaction (Smith & Newton, 2007). Two reviews, focusing on case management for dementia (Pimouguet et al., 2010)

or chronic illness among older or frail people (Oeseburg et al., 2009), reported reduced service use. A more recent review of case management for heart failure patients being discharged from hospitals provided evidence for significant reductions in readmission rates, as well as all-cause mortality at the 12-month follow-up (Takeda et al., 2012). Reviews that assessed interventions targeting interactions between hospitals and primary care or community services through care coordination activities pointed to improved satisfaction among those receiving the intervention (Langhorne et al., 2005; Simoens et al., 2011), as well as improved quality of life (Phillips et al., 2004; Steffen et al., 2009), but not reduced mortality (Langhorne et al., 2005; Chiu & Newcomer, 2007; Simoens et al., 2011).

There was consistency in findings across two reviews examining collaborative care approaches for those with depression, but as with the evidence on disease management approaches reported previously, studies were almost exclusively set in the USA (Gilbody, Bower & Whitty, 2006; van Steenbergen-Weijenburg et al., 2010). A more recent Cochrane review of collaborative care for depression and anxiety problems, which also included studies from countries outside the USA, found improvements in outcomes across several studies, but statistically significant improvements were not always maintained over time (Archer et al., 2012). Brink-Huis, van Achterberg & Schoonhoven (2008) reviewed collaborative organizational models in relation to pain management among adult cancer patients, finding that pain intensity and relief improved using integrated care processes.

Evidence from reviews that considered strategies involving a combination of case management, care coordination or collaborative care for a range of patient groups was difficult to summarize. In general, they tended to show improvements in clinical or functional outcomes and, in some cases, a trend towards reduced mortality rates (Shepperd et al., 2008; Tappenden et al., 2012). One review of interventions targeting patients with coexisting, multiple chronic conditions in primary and community care settings found limited evidence for these to impact outcomes, although a number of process indicators, such as provider behaviour did improve (Smith et al., 2012).


2.2.3 Economic impacts of disease management or integrated care

We report the economic impacts of disease management and integrated care, respectively drawing from our reviews. In the review of disease management, few studies explicitly considered costs, and where they did, the evidence tended to be inconsistent (Ofman et al., 2004). De Bruin et al. (2011) examined the impact of disease management programmes on health care expenditures for patients with diabetes, depression, heart failure or COPD. Of 31 studies considered in their review, 21 reported incremental health care costs per patient per year, and of these, 13 found evidence of cost savings, but these were typically not statistically significant or not tested for statistical significance. The authors noted substantial variation across studies with regard to the interventions (content and type), the economic evaluative approach used, the type of direct health care costs and cost categories considered, alongside a lack of reporting on reliability of estimates, highlighting the need for higher-quality studies. Consequently, the authors concluded that “although it is widely believed that disease management programs reduce health care expenditures, the present study shows that evidence for this claim is still inconclusive” (de Bruin et al., 2011:105), thereby calling for well-designed economic evaluations.

In our review of integrated care approaches, the most common economic outcome measures were use and cost, but reporting of measures was inconsistent and the quality of the evidence was often low (Nolte & Pitchforth, 2014). The majority of economic outcomes focused on hospital use through (re)admission rates, length of stay or admission days and emergency department visits. For example, among reviews that considered care coordinating activities at the hospital–primary care or community services interface reported evidence of reduced hospital use (Phillips et al., 2004; Langhorne et al., 2005; Chiu & Newcomer, 2007; Steffen et al., 2009; Simoens et al., 2011).

Most studies reported cost in terms of health care cost savings, most frequently in relation to hospital costs. There was some evidence of cost reduction in a number of reviews although findings were frequently based on a small number of original studies, or studies that only used a before/after design without control, or both (Phillips et al., 2004; Chiu & Newcomer, 2007; Brink-Huis, van Achterberg & Schoonhoven, 2008; Shepperd et al., 2008; Steffen et al., 2009; Althaus et al., 2011; Simoens et al., 2011). Philips et al. (2004) highlighted the impact of a health system setting on costs, demonstrating how pooled cost differences for comprehensive discharge planning for those with heart failure ranged from US$359 compared to usual care in non-US-based trials to US$536 in trials based in the USA. Tappenden et al. (2012) further noted, in a review of structured home-based, nurse-led health promotion, the importance of differentiating between initial and longer-term costs. Thus,


they reported how a community-based nursing programme for patients with Parkinson’s disease had initially increased costs, whereas over two years costs were lower.

Neumeyer-Gromen et al. (2004) and van Steenbergen-Weijenburg et al. (2010), both reporting on care approaches targeted at those with depression, reported an increase in costs associated with the intervention, but the cost per successfully treated patient was lower (Neumeyer-Gromen et al., 2004). A review by Jacob et al. (2012) of 30 studies of collaborative care for the management of depressive disorders also provided some evidence of potential cost savings associated with collaborative care compared with usual care. All three reviews drew on primary studies set in the USA.

Reviews also pointed to cost–effectiveness of selected integrated care approaches, although again the evidence base was weak, frequently relying on single trials of a given intervention. For example, one review of approaches targeting frequent hospital emergency department users found one trial that reported the intervention to be cost-effective (Althaus et al., 2011). Another review of structured home-based, nurse-led health promotion for older people at risk of hospital or care home admission concluded, based on three economic studies, that there was a high likelihood of cost savings associated with the intervention (Tappenden et al., 2012). However, one of the three studies suggested that there was little or no evidence for gains in quality-adjusted life years (QALYs) over usual care. Four reviews reported on cost per QALY as a measure of cost utility, providing mixed evidence of increased cost with integrated care approaches (Gilbody, Bower & Whitty, 2006; Steuten et al., 2009; van Steenbergen-Weijenburg et al., 2010; Simoens et al., 2011). Jacob et al. (2012) reported collaborative care for the management of depressive disorders to be cost-effective. Overall the evidence was difficult to interpret.

2.3 What we need to know: limitations of the existing evidence base

This overview of the evidence on approaches to enhance chronic care is arguably limited in that it considers published systematic reviews only. This means that, by necessity, we have had to rely on authors’ reporting of findings of original studies, which limits objective assessment, in particular, where observations from original studies were not described in detail. Furthermore, even the most recent reviews will not capture primary studies published over the past 12 months or so, and which might have provided additional insights into the overview presented here. At the same time, and echoing concerns reported by Ouwens et al. (2005) in their assessment of the evidence of integrated care programmes


as described earlier, it remains challenging to interpret the evidence from existing primary studies. Thus, as reviews reported here have shown, studies of what can broadly be subsumed under the heading of chronic care strategies or programmes tend to be very heterogeneous. Lack of precision in reporting of interventions, alongside variation in definitions and components of care, does make arriving at overarching conclusions at what is the best approach difficult. Indeed, as Ouwens et al. (2005) noted, such heterogeneity might lead to inappropriate conclusions about programme effectiveness and the application of findings. This further underlines the continued need for the use of consistent definitions and of better description of the content of interventions to enable comparison.

However, at the same time, and at the risk of simplifying what is inherently complex, we can derive some tentative observations from the evidence presented here. Specifically, what seems to be emerging is the value of targeted approaches to enhance outcomes of those with complex care needs. For example, evaluations that examined the impact of different care components point to an association between the format or modality of the intervention and reported outcomes. Thus, evidence from collaborative care models for the management of depressive disorders suggests that interventions were more effective when based in the community or when they involved nurses as case managers (Thota et al., 2012). Similarly, for persons with heart failure, the impact on outcomes was found to be stronger for those interventions that incorporated a multidisciplinary team approach (Roccaforte et al., 2005; Göhler et al., 2006). These observations concur with other review evidence that examined the effects of different coordinated care interventions (Powell Davies et al., 2008). That review showed that interventions using multiple strategies tended to be more successful in enhancing the health outcomes of patients than those using single strategies only. Specifically, approaches that helped structuring relationships between providers and between providers and patients through, for example, case management or multidisciplinary teams were found to be more likely to be effective.

Other evidence points to the need to develop approaches that more specifically target those who are most likely to benefit. For example, Pimouguet et al. (2011) showed how diabetes disease management may be more effective for patients with poor glycaemic control. Similar findings were recently reported for a large, population-based diabetes care intervention in the Netherlands (Elissen et al., 2012), although requiring further confirmation (Elissen et al., 2013a). Evidence supporting the use of targeted approaches was also provided in the review by Smith et al. (2012) of models of care for those with multimorbidity cited earlier. While highlighting the paucity of research into related strategies, the


review noted that organizational interventions that focus on the management of specific risk factors or that targeted specific areas of concern for patients, such as functional ability or the management of medicines, may be more effective than approaches not similarly targeted.

The review by Smith et al. (2012) further highlighted the need to integrate new interventions with the existing health care delivery structure to enhance their effectiveness. Related observations noted how the evidence of impact tended to be stronger for primary studies undertaken in the USA than for those done elsewhere, as was the case for studies of disease management for diabetes (Knight et al., 2005). Given that much of the available evidence tends to originate from the USA, the findings highlight a need for caution when considering transferring models across countries with different health systems, and for developing a more robust evidence base that takes account of the European context (Nolte & McKee, 2008a). Overall, these findings also point to the need for more systematic evaluation of new models of care as a means to inform the development of efficient and effective interventions to address the growing burden of chronic conditions in Europe and elsewhere.

2.4 Conclusions

In this chapter, we have reviewed the recent evidence on the effectiveness of various approaches to improving care for people with chronic conditions. We have highlighted the difficulties in differentiating and defining terms associated with different models of care. This is not only of academic concern but makes collating evidence to support assessments of best practice in the management of chronic illnesses very difficult.

Furthermore, evidence of the cost–effectiveness of different models is lacking, particularly in the European context. Findings from the USA that suggest certain chronic care approaches may yield cost savings may not be transferable to other health systems. In this context, it is important to note that it is clear from the literature that it is easier to improve processes of care than costs. The assumption that providing better care will save money will need to be scrutinized carefully. Policy-makers and payers need to be clear about whether their goal is quality improvement or cost reduction as these two are not necessarily compatible with one another (Øvretveit, 2009).

We have shown that, overall, strategies that involve multiple organizational strategies that are set in the community, involve nurses as case managers and incorporate a multidisciplinary team approach are more likely to be effective. The evidence that is available tends to be limited to a small set of conditions only, although arguably, by restricting the review reported here to published


systematic reviews, we will have missed more recent evidence from primary studies that have investigated the impact of disease management on a broader range of conditions.

One fundamental issue remains, which is related to the need to develop a system-wide model of care for patients with chronic disease. Disease-specific approaches, such as disease management programmes, are ill-suited to meet the needs of the typical patient in primary care who typically has multiple health problems with complex needs (Nolte & McKee, 2008a). Integrated care, which is most commonly associated with aiming to meet the needs of populations groups with diverse and complex needs, has been associated with improved patient and clinical outcomes. The challenge in this case is that it is not clear for how long initial improvements are sustained. Furthermore, evidence of interventions designed to improve outcomes in patients with coexisting multiple chronic conditions in primary and community care settings suggests that this may be an area with the most inconsistent evidence. Despite the need for more robust evaluations and general strengthening of the evidence base, we have drawn common lessons around modalities of interventions that are likely to be more effective.

Chapter 3

Approaches to chronic disease management in

EuropeEllen Nolte, Cécile Knai

This chapter provides an overview of the policy context for chronic disease management in 12 European countries and examines approaches to chronic disease management and models of care delivery that have been or are being implemented in these countries. It draws on detailed country reports, which are presented in an accompanying volume (Nolte & Knai, 2015. We begin with a concise overview of selected key features of the health care systems in each of the countries reviewed. We then describe the main types of chronic care approaches countries are employing, the nature and scope of professionals and health care providers involved, the extent to which patients are actively engaged or supported, the use of support structures, such as decision-making tools and guidance, approaches to financing and the use of financial incentives, and population(s) covered.

As noted earlier, it is beyond the scope of this book to provide a comprehensive inventory of all approaches being implemented in a given country; instead we have focused on a sample of approaches considered representative of a given health care system.

3.1 Key features of the health care systems in 12 European countries

Before discussing the specific policy context for chronic disease in the countries reviewed, it is important to understand some of the key characteristics of the health care systems and the principles of health service delivery in each of the countries to help placing into context the efforts to implement chronic care policies as described further on in this chapter.


All countries have a similar commitment to providing universal and reasonably equitable access to health care for their populations, but do so in different ways. Four countries (Denmark, England, Italy and Latvia) operate primarily tax-funded systems, while the health care systems in Austria, Estonia, France, Germany, Hungary, Lithuania and the Netherlands are primarily funded through statutory health insurance. Switzerland operates a mandatory private insurance system (Table 3.1).

Countries reviewed vary in relation to principal health care governance structures, with systems in England, France, Hungary, Latvia and Lithuania characterized by structures that tend to concentrate governance functions at the central (national) level, with decentralization of some functions to bodies at arm’s length from government. Elsewhere, administrative and political responsibility is partly or fully devolved to local or regional authorities (Denmark, Estonia, Italy) or federal states (Austria, Germany, Switzerland). In Austria, Germany and the Netherlands, corporate actors (for example, statutory health insurance (SHI), providers) also play an important role.

Table 3.1Principlesofhealthcarefinancingin12Europeancountries

Country Health expenditure (2012)

Main sources of funding for health care (% of total current health expenditure in 2012)

% of GDP US$ PPP

Austria 11.5 5065 Combination of SHI (40.5) and general taxation (35.0), VHI (4.0), OOP (15.2)

Denmark 11.2 4720 General taxation (85.5), VHI (1.8), OOP (12.6)

England (UK) 9.4 3495 General taxation (82.5), VHI (1.1), OOP (9.9)

Estonia 5.9 1385 National health insurance (69.1), general taxation (10.8), OOP (18.4)

France 11.7 4260 SHI (71.0), VHI (13.8), OOP (7.4), general taxation (5.9)

Germany 11.3 4617 SHI (67.6), general taxation (8.7), VHI (9.5), OOP (12.1)

Hungary 7.8 1729 SHI (52.3), general taxation (11.4), VHI (2.7), OOP (27.1)

Italy 9.2 3040 National and regional taxation (78.2), OOP (20.2)

Latvia 6.0 1188 General taxation (56.7), VHI (2.5), OOP (37.4)

Lithuania 6.7 1426 SHI (60.1), taxation (10.7), OOP (28.5)

Netherlands 12.4 5384 SHI (72.6), taxation (7.3), VHI (5.2), OOP (5.6)

Switzerland 11.3 6062 Mandatory health insurance (43.7), taxation (18.0), VHI (9.4), OOP (28.1)

Source: World Health Organization (2014).Notes: GDP: gross domestic product; PPP: purchasing power parity/capita (national currency unit per US$); SHI: statutory health insurance; VHI: voluntary health insurance; OOP: (household) out-of-pocket (expenditure).

Countries also vary in the organization of health care, with differences in the settings within which the different levels of care are being provided (Table 3.2). Focusing on primary care, most countries reviewed here offer a choice of primary care physician, usually a general practitioner (GP) or family physician

25Access to health care services within and between countries of the European Union

operating in independent practice. The only exceptions are Denmark and England where choice of primary care provider is presently restricted to within (small) geographical areas. All but four countries require registration with a primary care provider who typically acts as gatekeeper to specialist services. Exceptions are Austria, France, Germany and Switzerland, which principally offer almost unrestricted access to primary and specialist care providers in the ambulatory care system, with France and Germany recently introducing voluntary GP gatekeeping schemes to enhance care coordination; selected managed care schemes in Switzerland also restrict direct access to specialists.

Where gatekeeping is in place, some direct access to specialists may still be possible, with certain specialties exempted from requiring a GP referral, such as in Denmark, Estonia, Hungary, Italy and Latvia. Also, where registration with a GP (practice) is in place, payment of the primary care provider tends to be based on capitation, frequently in combination with fees for specific services or activities and, less frequently, performance-related elements (for example, England, Estonia, France, Hungary). Systems that do not require patient enrolment typically reimburse their primary care providers on a fee-for-service basis (France, Switzerland), while elements of capitation may also be used (Austria, Germany).

We have previously noted that health care systems in which patients have traditionally chosen their provider without formal enrolment, and where payment for services is mainly based on fee-for-service , may face the greatest challenges in adapting towards providing effective chronic care (Busse & Mays, 2008). These observations provide important context for better understanding the general approaches taken by individual countries to enhance care for people with chronic conditions, and the extent to which existing structures facilitate, or indeed hinder, the implementation of related policies and approaches.

3.2 The policy context for chronic care in Europe

Fragmentation of care, particularly between ambulatory or primary care and hospital or secondary care, and between the health and social care sectors remains a key concern in most health care systems (Nolte, Knai & McKee, 2008; Nolte & McKee, 2008c). In recent years, therefore, many European countries have sought to create a regulatory and policy framework to respond to chronic disease, generally aiming to promote approaches that better integrate care and improve coordination between sectors and levels of care. Detailed descriptions of the policy context in the countries reviewed for this book are provided in its accompanying volume (Nolte & Knai, 2015). In brief, in Germany, for example, the 2000 Health Care Reform Act introduced provisions for the


Table

3.2

Sel

ecte

d fe

atur

es o

f hea

lth c

are

syst

ems

in 1

2 E

urop

ean

coun

trie

s

Co

untr

yG

ove

rnan

ce o

f th

e p

ublic

hea

lth

syst

emP

rinc

iple

s o

f he

alth

car

e p

rovi

sio

n o

utsi

de

hosp

ital

Pay

men

t o

f p

rovi

der

sP

rovi

sio

n o

f p

rim

ary/

gen

eral

ist

and

sp

ecia

list

care

out

sid

e ho

spit

al

Cho

ice

of

pro

vid

er

in p

rim

ary/

am

bul

ato

ry c

are

GP

gat

ekee

pin

gP

aym

ent

of

phy

sici

ans

in p

rim

ary/

amb

ulat

ory

car

eP

aym

ent

of

hosp

ital

s (y

ear

intr

od

uced

)

Aus

tria

Sha

red

by c

entr

al

gove

rnm

ent,

nine

st

ate

gove

rnm

ents

an

d co

rpor

atis

t act

ors;

re

spon

sibi

lity

for

hosp

ital s

ecto

r m

ainl

y w

ith th

e fe

dera

l sta

tes

Office-basedprim

aryand

spec

ialis

t car

e ph

ysic

ians

; ou

tpat

ient

clin

ics

Yes

No

Ble

nded

sys

tem

of f

ee-f

or-s

ervi

ce

(FFS

) with

cap

itate

d el

emen

t for

bas

ic

serv

ices

; det

erm

ined

by

paym

ent

sche

mes

bas

ed o

n pu

blic

ser

vice

s or

priv

ate

law

and

sup

plem

ente

d by

bo

nusesdefinedbythestate

Per

form

ance

-or

ient

ed h

ospi

tal

financingsystem

(LK

F) (1

997)

Den

mar

kS

hare

d by

cen

tral

go

vern

men

t, re

gion

s an

d m

unic

ipal

ities

; re

gion

s an

d m

unic

ipal

ities

are

la

rgel

y re

spon

sibl

e fo

r or

gani

zing

hea

lth c

are

GP

s in

priv

ate

prac

tice

Yes,

with

in

specifiedlocalarea;

regi

stra

tion

with

GP

re

quire

d

Yes;

acc

ess

to s

peci

alis

t ca

re o

n re

ferr

al

only

exc

ept f

or

opht

halm

olog

ists

an

d de

ntis

ts

A c

ombi

natio

n of

cap

itatio

n pe

r pa

tient

and

FFS

, in

addi

tion

to

spec

ial f

ees

for

out-

of-h

ours

ser

vice

s,

tele

phon

e co

nsul

tatio

ns a

nd h

ome

visi

ts

Com

bina

tion

of

glob

al b

udge

t and

ac

tivity

-bas

ed

fund

ing

usin

g D

RG

s

Eng

land

Cen

tral

leve

l by

gov

ernm

ent

and

agen

cies

at

arm’slengthfrom

go

vern

men

t; lo

cal

orga

niza

tions

org

aniz

e he

alth

car

e de

liver

y

GP

s in

com

mun

ity-b

ased

pr

actic

es o

r he

alth

cen

tres

Withinspecified

smal

l are

a on

ly;

regi

stra

tion

with

GP

re

quire

d

Yes

Wei

ghte

d ca

pita

tion

base

d on

G

ener

al M

edic

al S

ervi

ces

cont

ract

, ne

gotia

ted

natio

nally

by

Dep

artm

ent

of H

ealth

with

NH

S E

mpl

oyer

s an

d G

P C

omm

ittee

of t

he B

ritis

h M

edic

al

Ass

ocia

tion;

plu

s el

emen

ts o

f FFS

an

d pe

rform

ance

-rel

ated

pay

men

t

Act

ivity

-bas

ed

paym

ent b

y re

sults

us

ing

heal

th

reso

urce

gro

ups

for

acut

e se

rvic

es

(200

3)

Est

onia

Con

cent

rate

d at

the

cent

ral l

evel

with

som

e in

volv

emen

t of l

ocal

au

thor

ities

esp

ecia

lly in

th

e ho

spita

l sec

tor

GP

s in

inde

pend

ent f

amily

pr

actic

e Ye

s; re

gist

ratio

n w

ith

GP

requ

ired

Yes;

dire

ct a

cces

s to

sel

ecte

d sp

ecia

lties

an

d fo

llow

-up

cons

ulta

tion

for

chro

nic

dise

ase

Com

bina

tion

of b

asic

allo

wan

ce,

capi

tatio

n fe

e, F

FS, w

ith a

dditi

onal

co

mpe

nsat

ion

for

thos

e pr

actic

ing

in

rem

ote

area

s; b

ased

on

nego

tiatio

ns

betw

een

SH

I and

Soc

iety

of F

amily

Physiciansforaperiodoffiveyears

DR

Gs

(200

4),

com

plem

ente

d by

pe

r di

em a

nd F

FS

paym

ents


Co

untr

yG

ove

rnan

ce o

f th

e p

ublic

hea

lth

syst

emP

rinc

iple

s o

f he

alth

car

e p

rovi

sio

n o

utsi

de

hosp

ital

Pay

men

t o

f p

rovi

der

sP

rovi

sio

n o

f p

rim

ary/

gen

eral

ist

and

sp

ecia

list

care

out

sid

e ho

spit

al

Cho

ice

of

pro

vid

er

in p

rim

ary/

am

bul

ato

ry c

are

GP

gat

ekee

pin

gP

aym

ent

of

phy

sici

ans

in p

rim

ary/

amb

ulat

ory

car

eP

aym

ent

of

hosp

ital

s (y

ear

intr

od

uced

)

Fran

ceTr

aditi

onal

ly

conc

entr

ated

at t

he

natio

nal l

evel

with

gr

adua

l dec

entr

aliz

atio

n of

(sel

ecte

d)

gove

rnan

ce fu

nctio

ns

to re

gion

al a

genc

ies

Office-basedprim

aryand

spec

ialis

t car

e ph

ysic

ians

Yes

Yes,

of a

sof

t typ

e (p

refe

rred

doc

tor

sche

me)

, with

strongfinancial

ince

ntiv

es fo

r pa

tient

s

FFS

; nat

iona

lly s

et c

over

age

of fe

es

base

d on

agr

eem

ents

bet

wee

n pr

ofes

sion

al o

rgan

izat

ions

and

SH

I ad

min

istr

atio

n; e

xtra

-billi

ng (c

once

rns

50%

of p

atie

nts)

; P4P

ele

men

t sin

ce

2009

bas

ed o

n in

divi

dual

con

trac

ts

betw

een

phys

icia

ns a

nd S

HI

DR

Gs

(pha

sed

in fr

om 2

004)

, su

pple

men

ted

by a

dditi

onal

pa

ymen

ts fo

r specificareas/

serv

ices

Ger

man

yS

hare

d by

cen

tral

go

vern

men

t, 16

sta

te

gove

rnm

ents

and

co

rpor

atis

t act

ors;

re

spon

sibi

lity

for

hosp

ital s

ecto

r m

ainl

y w

ith th

e fe

dera

l sta

tes

Office-basedprim

aryand

spec

ialis

t car

e ph

ysic

ians

Yes

Volu

ntar

y (G

P

cont

ract

s)

Com

bina

tion

of c

apita

tion

and

fee-

for

serv

ice

base

d on

cen

tral

ly n

egot

iate

d un

iform

val

ue s

cale

(EB

M) b

y th

e Fe

dera

l Ass

ocia

tion

of S

HI p

hysi

cian

s an

d th

e N

atio

nal A

ssoc

iatio

n of

SH

I Fu

nds

Ger

man

DR

Gs

(pha

sed

in fr

om

2003

)

Hun

gary

At c

entr

al le

vel b

y go

vern

men

t and

agenciesatarm

’s

leng

th fr

om g

over

nmen

t

Office-basedfamily

phys

icia

n; s

peci

alis

t ca

re in

pol

yclin

ics

and

disp

ensa

ries

Yes;

regi

stra

tion

with

fam

ily p

hysi

cian

re

quire

d

Yes,

in p

rinci

ple,

bu

t wid

e ra

nge

of

spec

ialis

t ser

vice

s ar

e ac

cess

ible

w

ithou

t ref

erra

l

Wei

ghte

d ca

pita

tion

plus

adj

ustm

ents

ba

sed

on p

rovi

der

char

acte

ristic

s

DR

Gs

(199

3);

outp

atie

nt

spec

ialis

t ser

vice

s on

a F

FS b

asis

Italy

Sha

red

by th

e ce

ntra

l go

vern

men

t and

the

20

regi

ons,

with

regi

ons

havi

ng e

xten

sive

au

tono

my

Office-basedGPs,typically

insolopractice;office-

base

d sp

ecia

lists

Yes;

regi

stra

tion

with

G

P re

quire

dYe

s; d

irect

ac

cess

to c

erta

in

spec

ialis

ts,

for

exam

ple

gyna

ecol

ogis

ts

Cap

itatio

n fe

e pl

us a

sha

re b

ased

on

par

ticip

atio

n in

pub

lic h

ealth

in

terv

entio

ns (v

acci

natio

n an

d sc

reen

ing)

, bas

ed o

n na

tiona

l co

ntra

ct a

nd re

gion

al a

gree

men

ts

DR

Gs

(199

5),

com

plem

ente

d by

cap

itatio

n or

gr

ants

for

sele

cted

se

rvic

es

Latv

iaC

once

ntra

ted

at

the

cent

ral l

evel

by

gove

rnm

ent a

nd

agenciesatarm

’s

leng

th fr

om g

over

nmen

t

Typi

cally

GP

in

inde

pend

ent p

ract

ice;

he

alth

cen

tres

Yes

Yes;

dire

ct

acce

ss to

cer

tain

sp

ecia

lists

Age

-wei

ghte

d ca

pita

tion

plus

fees

for

definedactivities,b

onuspayments

andfixedallowances

Cas

e-ba

sed

paym

ent,

per

diem

pl

us F

FS p

oint

s


Co

untr

yG

ove

rnan

ce o

f th

e p

ublic

hea

lth

syst

emP

rinc

iple

s o

f he

alth

car

e p

rovi

sio

n o

utsi

de

hosp

ital

Pay

men

t o

f p

rovi

der

sP

rovi

sio

n o

f p

rim

ary/

gen

eral

ist

and

sp

ecia

list

care

out

sid

e ho

spit

al

Cho

ice

of

pro

vid

er

in p

rim

ary/

am

bul

ato

ry c

are

GP

gat

ekee

pin

gP

aym

ent

of

phy

sici

ans

in p

rim

ary/

amb

ulat

ory

car

eP

aym

ent

of

hosp

ital

s (y

ear

intr

od

uced

)

Lith

uani

aC

once

ntra

ted

at th

e ce

ntra

l lev

elFa

mily

phy

sici

ans

in

inde

pend

ent p

ract

ice;

sp

ecia

list o

utpa

tient

car

e in

he

alth

cen

tres

Yes;

regi

stra

tion

with

GP

requ

ired

Yes

Age

-wei

ghte

d ca

pita

tion

plus

pa

ymen

t for

peo

ple

livin

g in

rur

al

area

s an

d in

cent

ive

paym

ents

for

cert

ain

liste

d se

rvic

es

Glo

bal b

udge

ts

plus

cas

e-ba

sed

paym

ent

The

Net

herla

nds

Sha

red

by fe

dera

l and

lo

cal a

utho

ritie

s an

d co

rpor

atis

t act

ors

GP

s in

gro

up p

ract

ices

Ye

s; re

gist

ratio

n w

ith G

P re

quire

dYe

s; a

cces

s to

sp

ecia

list c

are

on

refe

rral

onl

y

Com

bina

tion

of c

apita

tion

and

FFS

; m

axim

um re

mun

erat

ion

fees

for

GP

s ne

gotia

ted

betw

een

Nat

iona

l A

ssoc

iatio

n of

GP

s, H

ealth

Insu

rers

N

ethe

rland

s an

d M

inis

try

of H

ealth

, W

elfa

re a

nd S

port

Dia

gnos

is a

nd

trea

tmen

t co

mbi

natio

ns

DB

Cs

(200

5)

Sw

itzer

land

Sha

red

by th

e fe

dera

l an

d 26

can

tona

l go

vern

men

ts w

ith

the

cant

ons

havi

ng

exte

nsiv

e au

tono

my

Office-basedprim

aryand

spec

ialis

t car

e ph

ysic

ians

Yes

No,

exc

ept f

or

thos

e en

rolle

d in

m

anag

ed c

are

plan

s (1

2% o

f re

side

nts)

Inde

pend

ent h

ealth

car

e pr

ofes

sion

als

are

gene

rally

pai

d on

a F

FSs

basi

s;

som

e m

anag

ed c

are

plan

s op

erat

e ca

pita

tion

mod

els

Per

die

m p

lus

Sw

iss

DR

Gs

(from

200

9)

Sour

ces:

Ette

lt &

Nol

te (2

010)

, Ette

lt et

al.

(200

8); Th

omso

n, F

oubi

ster &

Mos

sialo

s (20

09);

the

auth

ors.

Not

es: G

P: g

ener

al p

ract

ition

er; F

FS: f

ee-fo

r-se

rvic

e; L

KF:

Lei

stung

sorie

ntie

rte

Kra

nken

ansta

ltenfi

nanz

ieru

ng (p

erfo

rman

ce-b

ased

fina

ncin

g); D

RG: d

iagn

osis-

rela

ted

grou

ps; N

HS:

nat

iona

l hea

lth se

rvic

e; S

HI:

statu

tory

hea

lth in

sura

nce;

P4P

: pay

-for-

perfo

rman

ce; E

BM: E

inhe

itlic

her B

ewer

tung

smaß

stab

(Uni

form

Ass

essm

ent S

cale

); D

BC: d

iagn

ose

beha

ndel

ing

com

bina

ties (

diag

nosis

and

trea

tmen

t com

bina

tions

).

Table

3.2

con

td


development of integrated care structures, linking the ambulatory care and hospital sectors (Busse & Riesberg, 2004). In Austria, the 2005 health reform led to the creation of a financial pool at the federal state level (reform pool) to promote coordination of and cooperation between ambulatory and hospital care (Hofmarcher & Rack, 2006). In England, the 2004 NHS Improvement Plan explicitly placed the care for those with chronic conditions at the centre of successive and ongoing reform efforts, emphasizing the need to strengthen the integration between providers and sectors (Nolte et al., 2015). This objective was also central to recent efforts in Hungary and Lithuania to strengthen chronic care (Gaal et al., 2015; Lai et al., 2015). Other reform efforts have aimed at supporting care coordination through the introduction and further development of nurse-led strategies in most countries reviewed here, although the degree to which relevant efforts have been implemented has varied, from nurses forming an integral part of primary care, such as in England and the Netherlands (Elissen et al., 2015; Nolte et al., 2015), or their deployment within defined areas of care delivery, such as in Austria, France and Germany (Chevreul et al., 2015; Erler, Fullerton & Nolte, 2015; Sönnichsen, Flamm & Nolte, 2015).

Several countries have introduced fundamental reforms which, although not necessarily implemented to specifically address chronic disease or indeed targeting the health care sector as such, have impacted on the ability of systems to develop an integrated policy response to the rising burden of chronic illness. Most notable are reforms of national administrative structures, as in Denmark and Italy (Frølich, Jacobsen & Knai, 2015; Ricciardi et al., 2015). For example, the 1992 Law 502 in Italy introduced the gradual decentralization of administrative and financial functions to regions and local authorities, which was further strengthened and expanded on by the 2001 constitutional reform and 2009 legislation stipulating fiscal autonomy of regional institutions. This has provided regions with the means to organize health care according to local need, but it has also meant that centrally planned policies tend to be fragmented and uncoordinated, resulting in considerable variation among (and within) regions. In Denmark, the 2007 administrative reform changed the way health care is funded and organized, with most responsibilities moved to regions while municipalities were made responsible for the cofinancing of health services. This sought to encourage municipalities to improve preventive services and so reduce use of hospital care, which is organized at the regional level.

Ideally, such reforms will pave the way for the development of a consistent and comprehensive policy response to chronic diseases, with elements of health promotion and primary prevention, early detection and treatment, to the management of co- and multimorbidities and complications to palliative


and end-of-life care. However, countries reviewed differ with regard to their vision for controlling and managing chronic disease, ranging from overarching strategies for chronic disease control, to specific policies addressing the various components along the care continuum, to a lack of explicit policy focus on chronic diseases altogether. Instead, the majority of countries considered here have implemented a range of policies targeting specific elements on the care continuum.

3.3 Overview of approaches to chronic disease management in 12 European countries

We reviewed some 50 approaches and groups of approaches to chronic disease management in 12 European countries. Given the highly selective nature of the types of approaches identified, we have refrained from attempting to quantify observed features, such as providing counts or proportions. Instead, we provide a narrative account of key observations, summarized in tabular format. Detailed information on each approach is included in the relevant country report presented in an accompanying volume to this book (Nolte & Knai, 2015).

Table 3.3 provides an overview of the type and aims of approaches that have been or are being implemented, the target populations addressed and the principal providers involved. Because the focus of this work has been specifically to identify and describe approaches that broadly seek to improve the care for those with chronic health problems, the stated aims of the various approaches typically have the improvement of the quality of care at their core. Frequently, approaches also consider some form of coordination or integration between providers or sectors as a further aim, alongside enhancing efficiency and, in some instances, reducing (hospital) use.

Importantly, the majority of approaches focus on care models for populations with defined conditions, most frequently targeting type 2 diabetes, followed by asthma/COPD, cardiovascular disease (mainly chronic heart failure, ischaemic heart disease, cardiovascular risk and stroke), cancer and mental health problems. However, several countries reviewed here are also implementing approaches with a broader focus, typically centring on older people. These tend to be available in selected regions only or are operated as pilot studies. Examples include the Integrated Care Pilot (ICP) programme and the Partnership for Older People Project (POPP) in England, the Coordinating Care for Older People programme (COPA) in Paris, France, selected integrated care contracts in Germany and the Care Coordination Pilot (CCP) in Hungary. Where care models have been implemented as a pilot, some have been adapted for implementation in other regions (for example, the COPA programme in


France) or are sustained beyond completion of the pilot phase (for example, selected POPP projects in England) (Table 3.3).

Three countries, Estonia, Latvia and Lithuania, have not (yet) established chronic disease management as a distinct concept (Lai & Knai, 2015; Lai, Knai & Taube, 2015; Lai et al., 2015). Instead, chronic care is seen to be embedded within the primary care system, which all three countries newly introduced in the 1990s, with the GP or family physician at the core. However, within this framework, these countries are implementing strategies specifically targeting (complex) chronic conditions.

Most approaches were introduced in the 2000s, with some in an ongoing process of implementation or pilot stage. Only a small number of service models described here date back to the 1990s or earlier; examples include an ambulatory after-care service for stroke in the State of Salzburg, Austria (1989), a stroke service in Delft, the Netherlands (1997), and the Delta physician network in Geneva, Switzerland (1992) (Table 3.3). This illustrates that chronic disease care has only relatively recently become the focus of health policy-makers, regulators, funders and other stakeholders, as noted in the introduction to this book. It also reflects the health care literature around approaches to, and models of care for chronic health problems, which has emerged from the mid-1990s onwards, largely evolving from accumulating evidence of the effectiveness of structured disease management in the USA (Nolte & McKee, 2008b). At the same time, it is important to recognize, as indicated here, that countries have experimented with new models of care well before the current chronic care debate, usually in the context of care for the frail older population at the interface between the cure and care sectors (shared care). Indeed, the Matador model of diabetes care described for the Maastricht region in the Netherlands has evolved from a shared care approach implemented in 1996 (Klein-Lankhorst & Spreeuwenberg, 2008).

As described in Table 3.3, the approaches implemented in the countries reviewed can be broadly categorized as care coordination, managed discharge, multidisciplinary team working, case management and nurse-led care. These distinctions do overlap, with case management and managed discharge frequently, although not always, led by (specialist) nurses, while care coordination and multidisciplinary team working tend to refer to a coordinated approach to providing care across different professions or disciplines, in some cases also involving different providers, for example, in the form of provider networks. Our simplified typology is largely driven by the principal coordinator or provider of patient care identified for each of the approaches described here. In most cases, this is the GP or family physician (DMPs in Austria and Germany; care groups in the Netherlands). Where multidisciplinary teams act


as principal coordinator, these are frequently led by a GP or other physicians, for example: selected integrated cure pilots in England; provider networks and local cancer networks in France; integrated cure contracts in Germany; treatment protocols and CCPs in Hungary; the “From On-Demand to Proactive Primary Care” programme in Tuscany, Italy; the DiaBaid diabetes care network and Delta physician network in Switzerland). Several countries also use nurse-led approaches, although it should be noted that these tend to be limited to a selected set of countries only, including England (nurse-led case management; selected integrated care pilots), Hungary (asthma and diabetes disease management), Italy IGEA diabetes care programme; Leonardo and Raffaello projects), and the Netherlands (Matador diabetes management programme; stroke service Delft).

Several countries have introduced enhanced roles for specialized nurses in a coordinating function or in case management, such as Denmark (integrated clinical pathways), the COPA coordination of professional care for the elderly programme and the ASALWW project in France, and Lithuania (case management pilot HIV/AIDS). The Sophia diabetes care programme in France uses trained nurses to lead on the main intervention to support patients; however, the patient’s GP remains the principal care coordinator. Similarly, the Kardiomobil home care for patients with chronic heart failure programme in Salzburg, Austria, involves a nurse-led intervention to support patient self-management of chronic heart failure. Although nurses act as the principal coordinators, they do so in collaboration with the patients’ GPs. Germany has introduced nurse-led projects based on the concept of a community nurse, with different formats being tested and implemented. The predominant model is that of a care assistant in family practice (for example, VerAH), with selected medical tasks delegated to the practice nurse but legally assigned and performed under the supervision of a GP.

A small number of approaches use care coordinators with a non-medical and non-nursing background. These approaches tend to focus on after-care, rehabilitation and general support schemes. Those involved include allied health professionals (for example, a team of therapists in the ambulatory after-care of stroke patients in Salzburg, Austria), social or hybrid (health and social care) workers (Partnership for Older People Project, England), volunteer organizations (Partnership for Older People Project, England) or skilled key workers (selected integrated care pilots, England). The care coordination/interface management programme in Styria, Austria, offered by the regional SHI fund, uses an employee of the fund as the principal coordinator for discharge management; similar approaches in other parts of Austria use nurses or social workers.


Table

3.3

Ove

rvie

w o

f app

roac

hes

to c

hron

ic d

isea

se m

anag

emen

t or

thei

r eq

uiva

lent

in 1

2 E

urop

ean

coun

trie

s

Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Aus

tria

‘Therapieaktiv’

dise

ase

man

agem

ent

prog

ram

me

To im

prov

e th

e qu

ality

of l

ife a

nd e

xten

d lif

e fo

r pe

ople

with

chr

onic

dis

ease

, to

plac

e th

e pa

tient

at t

he c

entr

e of

car

e an

d to

mak

e efficientuseofhealthcareresourcesandalso

redu

ce h

ospi

taliz

atio

ns

Car

e co

ordi

natio

nTy

pe 2

dia

bete

s pa

tient

s20

06D

MP

phy

sici

an

(GP

/fam

ily

phys

icia

n)

GP

s, s

peci

alis

ts,

diab

etes

adv

iser

s

Inte

grat

ed s

trok

e ca

re

Upp

er A

ustr

iaTo

impr

ove

care

for

patie

nts

with

str

oke

both

in

rela

tion

to a

cute

car

e an

d at

the

inte

rface

to

reha

bilit

atio

n

Man

aged

di

scha

rge

Str

oke

patie

nts

2005

GP

GP

s, s

peci

alis

ts in

/ou

tsid

e ho

spita

l, em

erge

ncy

serv

ices

, re

habi

litat

ion

Car

e co

ordi

natio

n/in

terfa

ce m

anag

emen

t S

tyria

To im

prov

e th

e co

ntin

uity

of c

are

follo

win

g di

scha

rge

from

hos

pita

l usi

ng a

car

e co

ordi

nato

r

Man

aged

di

scha

rge

Pat

ient

s in

ho

spita

l20

02–2

003

(p

ilot)

Car

e co

ordi

nato

r at

the

regi

onal

SH

I fu

nd

Car

e co

ordi

nato

r lia

ises

with

hos

pita

ls

and

GP

s

Am

bula

tory

afte

r-ca

re

of s

trok

e pa

tient

s,

Sal

zbur

g

To fa

cilit

ate

acce

ss to

spe

cial

ized

am

bula

tory

ca

re fo

r st

roke

pat

ient

s an

d th

ereb

y en

able

tim

ely

reha

bilit

atio

n an

d re

duce

hos

pita

l cos

ts

thro

ugh

early

dis

char

ge

Man

aged

pos

t-di

scha

rge

care

Str

oke

patie

nts

1989

Team

of t

hera

pist

s (n

euro

reha

bilit

atio

n te

am)

Occ

upat

iona

l, sp

eech

an

d ph

ysio

ther

apis

ts;

GP

s

Kar

diom

obil

– H

ome

care

for

patie

nts

with

ch

roni

c he

art f

ailu

re

To s

uppo

rt p

atie

nts

with

chr

onic

hea

rt fa

ilure

to

enh

ance

dis

ease

(sel

f)man

agem

ent,

redu

ce

hosp

ital (

re)a

dmis

sion

s an

d co

mpl

icat

ions

and

im

prov

e qu

ality

of l

ife

Nur

se-le

d ca

reC

hron

ic h

eart

fa

ilure

pat

ient

s20

04 (p

ilot)

Trai

ned

nurs

eG

Ps,

spe

cial

ists

, nu

rses

, hos

pita

ls,

hom

e ca

re s

ervi

ces

Den

mar

k

SIK

S p

roje

ct –

inte

grat

ed e

ffort

for

peop

le li

ving

with

ch

roni

c di

seas

e

To s

uppo

rt p

eopl

e w

ith c

hron

ic c

ondi

tions

(C

OP

D, t

ype

2 di

abet

es, c

hron

ic h

eart

failu

re,

IHD

, bal

ance

pro

blem

s) th

roug

h co

ordi

nate

d re

habi

litat

ion

Car

e co

ordi

natio

n Ty

pe 2

dia

bete

s,

asth

ma/

CO

PD

, chr

onic

he

art f

ailu

re,

IHD

, bal

ance

pr

oble

ms

amon

g ol

der p

eopl

e

2005

Mul

tidis

cipl

inar

y te

am a

t hea

lth c

are

cent

re/h

ospi

tal

(det

erm

ined

by

sev

erity

of

cond

ition

)

GP

s, s

peci

alis

ts

in h

ospi

tal,

(spe

cial

ist)

nurs

es,

phys

ioth

erap

ists

, di

etiti

ans

in h

ospi

tal

and

com

mun

ity

serv

ices


Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Den

mar

k co

ntd

Reg

iona

l dis

ease

m

anag

emen

t pr

ogra

mm

es

A c

ombi

ned,

inte

rdis

cipl

inar

y, in

ters

ecto

ral

andcoordinatedeffortforaspecificchronic

cond

ition

that

ens

ures

the

use

of e

vide

nce-

base

d re

com

men

datio

ns, a

pre

cise

de

scrip

tion

of ta

sks

and

coor

dina

tion

of a

nd

com

mun

icat

ion

betw

een

all p

artie

s in

volv

ed

Car

e co

ordi

natio

n Ty

pe 2

dia

bete

s,

CO

PD

, CV

D,

dem

entia

, m

uscu

losk

elet

al

diso

rder

s,

depr

essi

on,

schi

zoph

reni

a,

canc

er

2009

, ong

oing

D

MP

GP

GP

s, m

unic

ipal

hea

lth

care

cen

tre,

hos

pita

l sp

ecia

lists

Inte

grat

ed c

linic

al

path

way

sTo

ens

ure

fast

and

opt

imal

trea

tmen

t and

m

anag

emen

t of p

atie

nts

with

can

cer/

hear

t di

seas

e

Car

e co

ordi

natio

nH

eart

dis

ease

, ca

ncer

pat

ient

s20

08 (c

ance

r),

2010

(hea

rt

dise

ase)

Car

e (p

athw

ay)

coor

dina

tor

(spe

cial

ist n

urse

)

GP

s, s

peci

alis

ts,

nurs

es, h

ospi

tals

, m

ultid

isci

plin

ary

team

s

Eng

land

Cas

e m

anag

emen

t/co

mm

unity

mat

ron

To e

nabl

e in

tens

ive,

hom

e-ba

sed

case

m

anag

emen

t for

old

er p

eopl

e at

ris

k of

ho

spita

lizat

ion

and

othe

r hi

gh-in

tens

ity s

ervi

ce

user

s

Cas

e m

anag

emen

tO

lder

peo

ple

at r

isk

of

hosp

italiz

atio

n

2004

Spe

cial

ist n

urse

GP

s, s

peci

alis

ts,

nurs

es, h

ospi

tals

, co

mm

unity

car

e an

d so

cial

car

e se

rvic

es

Qua

lity

and

outc

omes

fra

mew

ork

(QO

F)To

mak

e th

e G

P p

rofe

ssio

n m

ore

attr

activ

e,

redu

ce th

e w

ide

varia

tion

in p

aym

ents

to

prac

tices

, fai

rly li

nk re

war

d to

wor

kloa

d, a

nd

help

redu

ce h

ealth

ineq

ualit

ies

GP

-led

syst

emG

ener

alis

t20

04G

PG

Ps,

nur

ses,

ph

arm

acis

ts,

spec

ialis

ts

Par

tner

ship

s fo

r ol

der

peop

le p

roje

ct (P

OP

P)

Toprovideperson‐centredandintegrated

serv

ices

for

olde

r pe

ople

, enc

oura

ge

inve

stm

ent i

n ca

re a

ppro

ache

s th

at p

rom

ote

heal

th, w

ell-b

eing

and

inde

pend

ence

, and

pr

even

t/de

lay

the

need

for

high

er in

tens

ity o

r in

stitu

tiona

l car

e

Inte

grat

ed

care

/pro

vide

r ne

twor

ks/c

ase

man

agem

ent/

man

aged

di

scha

rge

Old

er p

eopl

e (>

65

yea

rs)

2005

–201

0Va

ried:

m

ultid

isci

plin

ary

team

(hea

lth

and

soci

al c

are)

; so

cial

or

hybr

id

wor

ker;

vol

unte

er

orga

niza

tion

GP

s, h

ospi

tals

, nu

rses

, com

mun

ity

serv

ices

, soc

ial

care

, oth

er p

ublic

an

d vo

lunt

ary

and

com

mun

ity

orga

niza

tions

Table

3.3

con

td


Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Eng

land

con

td

Inte

grat

ed c

are

pilo

t pr

ogra

mm

eTo

impr

ove

the

qual

ity o

f car

e an

d ou

tcom

es

for

patie

nts,

enh

ance

par

tner

ship

s on

car

e provisionandmakemoreefficientuseof

scar

ce re

sour

ces

Inte

grat

ed

care

/pro

vide

r ne

twor

ks/c

ase

man

agem

ent/

man

aged

di

scha

rge

Gen

eral

ist a

nd

disease-specific

(for

exam

ple,

di

abet

es, C

OP

D,

dem

entia

)

2009

–201

1Va

ried:

GP

-le

d ca

re;

mul

tidis

cipl

inar

y te

am w

orki

ng;

nurs

e-le

d ca

se

man

agem

ent;

skille

d ke

y w

orke

r-le

d ca

re

coor

dina

tion

GP

s, h

ospi

tals

, nu

rses

, allie

d he

alth

pr

ofes

sion

als,

co

mm

unity

ser

vice

s,

soci

al c

are,

oth

er

publ

ic a

nd v

olun

tary

se

rvic

es

Est

onia

Qua

lity

man

agem

ent i

n pr

imar

y he

alth

car

eC

hron

ic d

isea

se m

anag

emen

t as

a co

ncep

t no

t est

ablis

hed

but i

ndire

ctly

em

bedd

ed in

the

over

all s

truc

ture

and

org

aniz

atio

n of

the

heal

th

care

sys

tem

GP

-led

care

Type

2 d

iabe

tes,

ca

rdio

vasc

ular

di

seas

e (c

hron

ic

hear

t fai

lure

, IH

D)

2003

(c

ompl

etio

n of

G

P s

yste

m)

GP

GP

s, s

peci

alis

ts,

nurs

es, a

llied

heal

th

prof

essi

onal

s (fo

r ex

ampl

e,

phys

ioth

erap

ists

), so

cial

car

e

Chr

onic

dis

ease

m

anag

emen

t at t

he

prim

ary/

seco

ndar

y ca

re

inte

rface

Chr

onic

dis

ease

man

agem

ent a

s a

conc

ept

not e

stab

lishe

d bu

t ind

irect

ly e

mbe

dded

in th

e ov

eral

l str

uctu

re a

nd o

rgan

izat

ion

of th

e he

alth

ca

re s

yste

m

Spe

cial

ist-

led

care

Mul

tiple

sc

lero

sis,

Parkinson’s

dise

ase,

sc

hizo

phre

nia,

C

OP

D

Vario

usS

peci

alis

t (ce

ntre

); co

mor

bidi

ties

man

aged

by

GP

in

coor

dina

tion

with

sp

ecia

list

GP

s, s

peci

alis

ts,

nurs

es, a

llied

heal

th

prof

essi

onal

s,

hosp

itals

, soc

ial c

are,

sp

ecia

list c

entr

es

(mul

tiple

scl

eros

is)

Fran

ceP

rovi

der

netw

orks

For

exam

ple,

dia

bete

s ne

twor

ks: R

EV

ES

DIA

BTo

impr

ove

the

qual

ity o

f car

e fo

r pe

ople

with

ty

pe 2

dia

bete

sM

ultid

isci

plin

ary

team

Ty

pe 2

dia

bete

s20

01P

athw

ay

coor

dina

tor:

GP

or

nurs

e

GP

s, s

peci

alis

ts,

nurs

es, a

llied

heal

th

prof

essi

onal

s (d

ietit

ians

, the

rapi

sts)

, ho

spita

ls, l

abor

ator

ies


Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Fran

ce c

ontd

Pro

vide

r ne

twor

ksFo

r ex

ampl

e,

Coo

rdin

atio

n of

pr

ofes

sion

al c

are

for

the

elde

rly (C

OPA

)

To b

ette

r in

tegr

ate

serv

ice

prov

isio

n be

twee

n he

alth

and

soc

ial c

are;

to re

duce

inap

prop

riate

he

alth

car

e us

e, in

clud

ing

emer

genc

y de

part

men

t and

hos

pita

l use

; to

prev

ent l

ong-

term

nur

sing

hom

e in

stitu

tiona

lizat

ion

Cas

e m

anag

emen

tFr

ail o

lder

peo

ple

(> 6

5 ye

ars)

2006

Spe

cial

ist n

urse

as

case

man

ager

GP

s, s

peci

alis

ts,

nurs

es, h

ospi

tals

, allie

d he

alth

pro

fess

iona

ls

(psy

chol

ogis

ts,

ther

apis

ts),

soci

al

serv

ices

Spe

cific

pro

gram

mes

Sop

hia

diab

etes

an

d as

thm

a ca

re

prog

ram

me

(by

SH

I)

Toim

proveself-managem

ent,efficiencyand

qual

ity o

f dia

betic

car

e; n

atio

nwid

eC

are

coor

dina

tion

Type

1 a

nd 2

di

abet

es, a

sthm

a20

08

(dia

bete

s),

2014

(ast

hma)

GP,

in c

olla

bora

tion

with

nur

seG

Ps,

nur

ses

Hea

lth A

ctio

n by

Tea

ms

of S

elf-

Em

ploy

ed

Hea

lth P

rofe

ssio

nals

(A

SA

LEE

)

To im

prov

e he

alth

car

e qu

ality

by

dele

gatin

g se

lect

ed ta

sks

to n

urse

s N

urse

-led

care

Dia

bete

s, C

VD

2004

–200

7Tr

aine

d nu

rse

GP

s, n

urse

s

Hos

pita

l dis

char

ge

prog

ram

me

for

hear

t fa

ilure

pat

ient

s (P

RA

DO

)

Ada

pt a

nd im

prov

e fo

llow

-up

care

afte

r ho

spita

l dis

char

geC

are

coor

dina

tion/

man

aged

di

scha

rge

Pat

ient

s ho

spita

lized

for

hear

t fai

lure

2013

Dis

char

ge m

anag

erG

Ps,

car

diol

ogis

ts,

nurs

es

Specificpayment

base

d on

pub

lic h

ealth

ob

ject

ives

(RO

SP

)

Rew

ard

achi

evem

ent o

f obj

ectiv

es in

the

fieldsofprevention,chronicdiseasecareand

pres

crip

tion

Phy

sici

an-le

d sy

stem

GP

s an

d sp

ecia

list

phys

icia

ns

2009

(pilo

t: C

AP

I) 20

12 (f

ull

roll-

out)

Phy

sici

anG

Ps

and

spec

ialis

t ph

ysic

ians

Mea

sure

s in

the

2003

–200

7 C

ance

r P

lan

Pro

toco

l for

dis

ease

co

mm

unic

atio

n an

d pr

omot

ion

of s

hare

d de

cisi

on-m

akin

g (Dispo

sitifd’annonce)

To im

prov

e th

e or

gani

zatio

n of

pro

cess

es

and

com

pete

ncie

s in

dis

cuss

ing

a ca

ncer

di

agno

sis,

and

pro

mot

ing

shar

ed d

ecis

ion-

mak

ing

betw

een

prof

essi

onal

s, p

atie

nts

and

thei

r ca

rers

Car

e pr

otoc

olC

ance

r20

04S

peci

alis

tG

Ps,

spe

cial

ists

, nu

rses

, allie

d he

alth

pr

ofes

sion

als

(for

exam

ple,

psy

chol

ogis

ts),

soci

al w

orke

rs

Table

3.3

con

td


Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Fran

ce c

ontd

Mea

sure

s in

the

2003

–200

7 C

ance

r P

lan

cont

dM

ultid

isci

plin

ary

team

m

eetin

g (R

CP

)To

pro

mot

e th

e sy

stem

atic

use

of a

m

ultid

isci

plin

ary

team

in th

e de

velo

pmen

t of

the

Can

cer

Car

e pl

an s

o as

to im

prov

e th

e qu

ality

of c

ance

r di

agno

sis,

trea

tmen

t and

su

ppor

t

Mul

tidis

cipl

inar

y te

amC

ance

r20

04M

édec

in r

éfér

ent

(doctor’sreferral,

frequ

ently

sur

geon

)

Spe

cial

ists

, hos

pita

ls;

mul

tidis

cipl

inar

y te

am

com

pris

es a

s m

inim

um

surg

eon,

rad

iolo

gist

an

d on

colo

gist

Reg

iona

l can

cer

netw

orks

To c

oord

inat

e al

l rel

evan

t act

ors

and

leve

ls

of c

are

in th

e m

anag

emen

t of c

ance

r, an

d to

gu

aran

tee

qual

ity a

nd e

quity

of c

are

acro

ss a

ll re

gion

s

Car

e co

ordi

natio

n/pr

ovid

er

netw

ork

Can

cer

2004

As

in R

CP

Spe

cial

ists

, nur

ses,

ph

arm

acis

ts, h

ospi

tals

Loca

l can

cer

or lo

cal

mul

tiple

pat

holo

gy

netw

orks

To fa

cilit

ate

the

loca

l man

agem

ent a

nd

mon

itorin

g of

can

cer

patie

nts

thro

ugh

bett

er

inte

grat

ion

of G

Ps

into

net

wor

ks o

f can

cer c

are

Car

e co

ordi

natio

nC

ance

r20

04G

PG

Ps,

spe

cial

ists

, nu

rses

, allie

d he

alth

pr

ofes

sion

als,

ph

arm

acis

ts, h

ospi

tals

, so

cial

wor

kers

Ger

man

y

Dis

ease

man

agem

ent

prog

ram

mes

Org

aniz

atio

nal a

ppro

ach

to m

edic

al c

are

that

invo

lves

the

coor

dina

ted

trea

tmen

t and

ca

re o

f pat

ient

s w

ith c

hron

ic d

isea

se a

cros

s bo

unda

ries

betw

een

indi

vidu

al p

rovi

ders

on

thebasisofscientificandupto

dateevidence

Car

e co

ordi

natio

n Ty

pe 1

and

2

diab

etes

, IH

D

(+ h

eart

failu

re),

brea

st c

ance

r, as

thm

a/C

OP

D

2002

DM

P p

hysi

cian

GP

s, s

peci

alis

ts,

hosp

itals

GP

con

trac

tsTo

impr

ove

the

coor

dina

tion

of c

are

and

stre

ngth

en th

e ro

le o

f prim

ary

care

in th

e G

erm

an h

ealth

sys

tem

Car

e co

ordi

natio

nG

ener

alis

t (so

me

cont

ract

s ta

rget

th

e ov

er 6

5s)

2004

GP

/fam

ily p

hysi

cian

GP

s, n

urse

s

Inte

grat

ed c

are:

Hea

lthy

Kin

zigt

alToestablishmoreefficientandorganized

heal

th c

are

for

the

resi

dent

s of

the

Kin

zigt

al

area

Car

e co

ordi

natio

n G

ener

alis

t 20

05C

are

coor

dina

tor

(phy

sici

an/

psyc

hoth

erap

ist)

GP

s, s

peci

alis

ts,

psyc

hoth

erap

ists

,ho

spita

ls, p

harm

acis

ts,

allie

d he

alth

pro

fess

iona

ls;co

ordi

nate

d by

man

agem

ent

orga

niza

tion


Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Ger

man

y co

ntd

Com

mun

ity n

urse

s:

care

ass

ista

nt in

fam

ily

prac

tice

(for

exam

ple,

Ve

rAH

)

To s

uppo

rt G

P s

ervi

ces

in u

nder

serv

ed a

reas

Nur

se-le

d ca

re

Gen

eral

ist

(alth

ough

ty

pica

lly ta

rget

ing

the

over

65s

)

2005

Pra

ctic

e as

sist

ant

GP,

pra

ctic

e as

sist

ant

Hun

gary

Trea

tmen

t (an

d financing)protocols

To c

ontr

ol c

osts

of t

reat

men

t, su

ch a

s th

ose

for

expe

nsiv

e dr

ugs

in th

e ca

se o

f can

cer

care

Use

of

trea

tmen

t gu

idel

ines

Ast

hma/

CO

PD

, C

VD

(hea

rt

failu

re, I

HD

, st

roke

), ca

ncer

2005

(can

cer)

Varie

s by

dis

ease

(fo

r ex

ampl

e, G

P

for

hype

rten

sion

; sp

ecia

list f

or

canc

er)

GP

s, s

peci

alis

ts,

nurs

es, h

ospi

tals

, sp

ecia

list c

entr

es

(can

cer

disp

ensa

ry,

pulm

onar

y di

spen

sary

)

Car

e co

ordi

natio

n pi

lot

(CC

P)

To in

cent

iviz

e pr

ovid

ers

to ta

ke re

spon

sibi

lity

for

the

spec

trum

of s

ervi

ces

(prim

ary

to te

rtia

ry

care)foranenrolledpo

pulationinadefined

area

Car

e co

ordi

natio

n G

ener

alis

t19

98/9

9–20

08C

are

coor

dina

tion

orga

niza

tion:

GP

s/

grou

ps o

f GP

s,

poly

clin

ic o

r hos

pita

l

GP

s, s

peci

alis

ts,

nurs

es, a

llied

heal

th

prof

essi

onal

s,

hosp

itals

, pha

rmac

ists

Mul

tifun

ctio

nal

com

mun

ity c

entr

esToim

proveefficiencyinthehealthcaresystem

th

roug

h be

tter

qua

lity

of c

are

at lo

wer

cos

tsM

ultid

isci

plin

ary

team

sG

ener

alis

tO

ngoi

ngC

omm

unity

cen

tre

GP

s, s

peci

alis

ts,

nurs

es, p

harm

acis

ts,

soci

al c

are

Ast

hma

dise

ase

man

age-

men

t pro

gram

me

To e

nhan

ce th

e qu

ality

of a

sthm

a ca

re

Nur

se-le

d ca

reA

sthm

a20

04S

peci

alis

t (as

thm

a)

nurs

eN

urse

s, s

peci

alis

ts,

disp

ensa

ries

Dia

bete

s ca

re

man

agem

ent

prog

ram

me

To im

prov

e th

e ca

re o

f pat

ient

s w

ith ty

pe 2

di

abet

es th

roug

h a

rang

e of

mea

sure

s, w

ith

nurs

e-le

d ca

re a

t its

cor

e

Nur

se-le

d ca

reTy

pe 2

dia

bete

sVa

rious

D

iabe

tes

spec

ialis

t (p

hysi

cian

, nur

se)

Spe

cial

ists

, nur

ses,

ho

spita

ls, s

peci

alis

t di

abet

es o

utpa

tient

uni

ts

Italy

Dia

bete

s in

tegr

atio

n,

man

agem

ent a

nd

assi

stan

ce (I

GE

A)

Nat

iona

l str

ateg

y to

sup

port

the

impl

emen

tatio

n of

dis

ease

man

agem

ent f

or

type

2 d

iabe

tes

at th

e re

gion

al le

vel

Mul

tidis

cipl

inar

y te

am a

nd c

ase

man

agem

ent

Type

2 d

iabe

tes

2006

Mul

tidis

cipl

inar

y te

am/n

urse

(cas

e m

anag

emen

t)

GP

s, s

peci

alis

ts,

nurs

es, a

llied

heal

th

prof

essi

onal

s (fo

r ex

ampl

e, d

ietit

ian,

ps

ycho

logi

st),

hosp

itals

Table

3.3

con

td


Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Italy

con

td“F

rom

On-

Dem

and

to

Pro

activ

e P

rimar

y C

are”

pr

ogra

mm

e, T

usca

ny

A th

ree-

year

str

ateg

y to

war

ds th

e de

velo

pmen

t of

a n

ew o

rgan

izat

iona

l app

roac

h to

hea

lth

care

that

em

phas

izes

pro

activ

e pa

tient

car

e

Mul

tidis

cipl

inar

y te

am

Hyp

erte

nsio

n,

diab

etes

, chr

onic

he

art f

ailu

re,

CO

PD

, str

oke

2009

Mul

ti-pr

ofes

sion

al

team

s (m

odul

e) (G

P

lead

, com

mun

ity

heal

th d

octo

r, sp

ecia

list n

urse

)

GP

s, s

peci

alis

ts,

nurs

es, a

llied

heal

th

prof

essi

onal

s (fo

r ex

ampl

e, d

ietit

ian,

ps

ycho

logi

st),

soci

al

serv

ices

Leon

ardo

pilo

t pro

ject

, P

uglia

To im

prov

e th

e qu

ality

and

effe

ctiv

enes

s of

he

alth

car

e fo

r th

ose

with

chr

onic

con

ditio

ns

and

to fa

cilit

ate

syst

emat

ic in

tegr

atio

n in

to th

e ex

istin

g or

gani

zatio

nal f

ram

ewor

k se

t by

loca

l he

alth

age

ncie

s

Nur

se-le

d ca

re

Type

1 a

nd 2

di

abet

es, c

hron

ic

hear

t fai

lure

, hig

h ca

rdio

vasc

ular

ris

k

2004

–200

7S

peci

alis

t nur

seG

Ps,

nur

ses,

sp

ecia

lists

Raf

fael

lo p

roje

ct,

Mar

che

and

Abr

uzzo

Res

earc

h pr

ojec

t to

asse

ss th

e ef

fect

iven

ess

of a

n in

nova

tive

mod

el o

f pat

ient

car

e fo

r th

e pr

even

tion

of c

ardi

ovas

cula

r di

seas

e on

the

basi

s of

dis

ease

and

car

e m

anag

emen

t in

gene

ral p

ract

ice

Nur

se-le

d ca

re

Type

1 a

nd

2 di

abet

es,

card

iova

scul

ar

risk

2007

Spe

cial

ist n

urse

GP

s, n

urse

s

Latv

ia

Gen

eral

prim

ary

heal

th

care

sys

tem

Not

app

licab

leN

ot a

pplic

able

Gen

eral

ist

1996

–199

8 (p

rimar

y he

alth

ca

re re

form

)

GP

GPs,doctor’s

assi

stan

t (fe

ldsh

er),

nurs

e, m

idw

ife,

dentist,dentist’s

assi

stan

t, de

ntal

nu

rse

and

dent

al

hygi

ene

spec

ialis

t

Lith

uani

a

Impr

ovin

g in

ters

ecto

ral

colla

bora

tion

To im

prov

e co

llabo

ratio

n be

twee

n he

alth

and

so

cial

car

eC

ase

man

agem

ent

(pilo

t)

Gen

eral

ist a

nd

disease-specific

(dia

bete

s, C

VD

, ca

ncer

, chr

onic

re

nal f

ailu

re, m

ultip

le

scler

osis,

dep

ress

ion,

H

IV/A

IDS

)

From

200

4 N

urse

GP

s, s

peci

alis

ts,

prov

ider

s of

ed

ucat

iona

l and

soc

ial

serv

ices


Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Lith

uani

a co

ntd

Clin

ical

gui

delin

esTo

con

trol

med

icat

ion

cost

s; to

impr

ove

colla

bora

tion

betw

een

prim

ary

and

seco

ndar

y ca

re

Use

of c

linic

al

guid

elin

esD

iabe

tes,

CV

D,

brea

st c

ance

r, ch

roni

c re

nal

failu

re, m

ultip

le

scle

rosi

s,

depr

essi

on; h

igh-

inte

nsity

use

rs

From

200

2G

P/s

peci

alis

t (d

epen

ding

on

heal

th p

robl

em)

GP

s, s

peci

alis

ts,

nurs

es, a

llied

heal

th

prof

essi

onal

s,

hosp

itals

Net

herla

nds

Mat

ador

DM

P/

Maa

stric

ht-H

euve

lland

Bui

lds

on a

pilo

t sch

eme

esta

blis

hed

in 1

996,

w

hich

use

d sp

ecia

lized

dia

bete

s nu

rses

to

redu

ce th

e nu

mbe

r of p

atie

nts

seen

by

med

ical

sp

ecia

lists

in o

utpa

tient

car

e

Mul

tidis

cipl

inar

y te

amTy

pe 2

dia

bete

s20

00–2

006

Cor

e te

am o

f G

P, s

peci

alis

t di

abet

es n

urse

and

en

docr

inol

ogis

t

GP

s, s

peci

alis

ts,

nurs

es, h

ospi

tals

Prim

ary

care

gro

up Z

iO

(Maa

stric

ht-H

euve

lland

)Th

e pr

imar

y ca

re g

roup

des

crib

es th

e w

hole

co

ntin

uum

of c

are

for

diab

etes

pat

ient

s an

d is

financedonthebasisofthebundledpaym

ent

syst

em

Car

e co

ordi

natio

n Ty

pe 2

dia

bete

s (m

ore

rece

ntly

al

so a

sthm

a/C

OP

D,

card

iova

scul

ar

dise

ase)

From

200

7G

PG

Ps,

spe

cial

ists

, nu

rses

, allie

d he

alth

pr

ofes

sion

als,

ho

spita

ls

Str

oke

serv

ice

Del

ftE

volv

ed fr

om a

pilo

t pro

ject

for

impr

ovin

g st

roke

car

e in

itiat

ed in

199

7 an

d fu

nded

by

the

Net

herla

nds

Inst

itute

for

Hea

lth R

esea

rch

and

Dev

elop

men

t

Mul

tidis

cipl

inar

y te

am

Str

oke

1997

(pilo

t)S

hare

d ca

re n

urse

GP

s, s

peci

alis

ts,

nurs

es, h

ospi

tals

, al

lied

heal

th

prof

essi

onal

s, n

ursi

ng

hom

es, r

ehab

ilitat

ion

cent

res,

hom

e ca

re

orga

niza

tion

Nat

iona

l car

e st

anda

rd

for

vasc

ular

ris

k m

anag

emen

t

Des

crib

es th

e m

inim

um re

quire

men

ts fo

r ap

prop

riate

, pat

ient

-cen

tred

car

e al

ong

the

care

con

tinuu

m fr

om p

reve

ntio

n an

d ea

rly

dete

ctio

n to

trea

tmen

t and

reha

bilit

atio

n (th

ere

are

sim

ilar

stan

dard

s fo

r di

abet

es a

nd a

sthm

a/C

OP

D)

Mul

tidis

cipl

inar

y te

amVa

scul

ar r

isk

From

201

0C

entr

al c

areg

iver

(d

eter

min

ed b

y pr

ogra

mm

e)

GP

s, s

peci

alis

ts,

nurs

es, h

ospi

tals

, al

lied

heal

th

prof

essi

onal

s,

mun

icip

al h

ealth

se

rvic

es, p

harm

acis

ts,

reha

bilit

atio

n se

rvic

es

Table

3.3

con

td


Nam

eA

im/g

ener

al d

escr

ipti

on

Typ

e o

f ap

pro

ach

Targ

et

po

pul

atio

nYe

ar

imp

lem

ente

dP

rinc

ipal

co

ord

inat

or

Pro

vid

ers

invo

lved

Sw

itzer

land

Dia

Bai

d di

abet

es c

are

netw

ork

Dev

elop

ed fr

om a

n in

vent

ory

of th

e ne

eds

of d

iabe

tic p

atie

nts

in th

e re

gion

of N

yon–

Mor

ges,

Can

ton

de V

aud

and

the

crea

tion

of

a w

orki

ng g

roup

of h

ealth

car

e st

akeh

olde

rs

invo

lved

in d

iabe

tes

care

Mul

tidis

cipl

inar

y te

amTy

pe 1

and

2

diab

etes

2004

End

ocrin

olog

ist–

diab

etol

ogis

tS

peci

alis

ts, n

urse

s,

allie

d he

alth

pr

ofes

sion

als

(die

titia

n, p

odol

ogis

t)

Bre

ast c

ance

r cl

inic

al

path

way

, Lau

sann

e U

nive

rsity

Hos

pita

l and

La

usan

ne U

nive

rsity

Toim

provethequalityandefficiencyofhealth

care

Mul

tidis

cipl

inar

y te

amB

reas

t can

cer

2008

–200

9H

ospi

tal (

onco

logy

)S

peci

alis

ts, n

urse

s,

allie

d he

alth

pr

ofes

sion

als

(phy

siot

hera

pist

s,

psyc

holo

gist

s), s

ocia

l w

orke

rs

Del

ta p

hysi

cian

ne

twor

k, G

enev

aP

hysi

cian

net

wor

ks fo

rm p

art o

f the

se

rvic

e st

ruct

ure

in a

mbu

lato

ry c

are;

Del

ta

was

con

ceiv

ed a

s an

HM

O a

nd in

200

4 tr

ansf

orm

ed in

to a

phy

sici

an n

etw

ork

Man

aged

car

eG

ener

alis

t; D

MP

s fo

r di

abet

es,

hear

t fai

lure

and

as

thm

a un

der

deve

lopm

ent

1992

Prim

ary

care

ph

ysic

ians

/GP

sP

rimar

y ca

re

phys

icia

ns,

phar

mac

ists

, ps

ycho

logi

sts

Sour

ces:

Austr

ia: S

önni

chse

n, F

lam

m &

Nol

te (2

015)

; Den

mar

k: F

rølic

h, Ja

cobs

en &

Kna

i (20

15);

Engl

and:

Nol

te e

t al.

(201

5); E

stoni

a: L

ai &

Kna

i (20

15);

Fran

ce: C

hevr

eul e

t al.

(201

5); G

erm

any:

Erle

r, Fu

llert

on &

Nol

te (2

015)

; Hun

gary

: Gaa

l et a

l. (2

015)

; Ita

ly: R

icci

ardi

et a

l. (2

015)

; Lith

uani

a: L

ai e

t al.

(201

5); L

atvi

a: L

ai, K

nai &

Tau

be (2

015)

; the

Net

herla

nds:

Eliss

en e

t al.

(201

5); S

witz

erla

nd: P

eytre

man

n-Br

idev

aux

et a

l. (2

015)

.


3.4 Financing, distribution and uptake of approaches to chronic disease management

The majority of approaches reviewed are funded within the public health care system, frequently supplemented by additional resources made available through (time-limited) funds earmarked for care coordination and integration initiatives, for example: reform pool projects in Austria, such as the Therapie aktiv diabetes management programme; regional diabetes management programme in Denmark; the quality management framework for diabetes and chronic CVD care in Estonia; the FIQCS intervention fund for quality and care coordination in France to support provider networks; integrated care contracts in Germany; and the ministry of mealth ‘special programmes’ fund in Italy (Table 3.4). In several cases, additional funding has provided a one-off start-up grant to support project implementation; examples include the two major pilot programmes in England (Partnership for Older People Projects; integrated care contracts) and, until 2009, integrated care contracts in Germany. There are examples of additional funding provided by the pharmaceutical industry, including, in Hungary, the asthma disease management and diabetes care programmes, and in Italy, the Leonardo and Raffaello diabetes disease and care management projects.

Several approaches use financial incentives, usually targeted at physicians. These typically involve additional reimbursement for documentation, patient enrolment or regular assessment (for example, the DMPs in Austria and Germany; the Sophia diabetes and asthma care programme in France) or for quality improvement activities (quality management in primary health care in Hungary; GP contracts in Germany; the Delta physician network in Switzerland). Selected approaches also involve elements of pay-for-performance or financial risk sharing of providers. Examples include the CCP in Hungary; “From On-Demand to Proactive Primary Care” programme in Tuscany, Italy; the Leonardo project in Puglia, Italy; and the primary care group/bundled payment systems in the Netherlands.

Given that most of the approaches reviewed here are funded within the statutory system, patient access is typically granted in line with access to usual care. Indeed, the majority of approaches are free of charge. Only a small number require co- or full payment by patients to enable access, for example, ambulatory after-care for stroke patients in Salzburg, Austria (with exemption from co-payments for those on low incomes). Some approaches offer explicit incentives for patients to participate. These typically include exemption from co-payments for usual care services they would otherwise have to pay for (for example, provider networks in France).


Table

3.4

Fin

anci

ng, d

istr

ibut

ion

and

upta

ke o

f app

roac

hes

to c

hron

ic d

isea

se m

anag

emen

t or

thei

r eq

uiva

lent

in 1

2 E

urop

ean

coun

trie

s

Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Aus

tria

‘The

rapi

e aktiv’d

isease

man

agem

ent

prog

ram

me

Reg

iona

l SH

I fun

d an

d fe

dera

l sta

te a

t abo

ut

50%

eac

h; p

rogr

amm

e de

velo

pmen

t fun

ded

by

regi

onal

SH

I fun

ds

Targ

eted

at D

MP

ph

ysic

ians

: pat

ient

si

gn-u

p an

d qu

arte

rly

fee

for

trea

tmen

t and

do

cum

enta

tion

Free

acc

ess

for

part

icip

atin

g pa

tient

s to

ed

ucat

ion

clas

ses

and

mat

eria

ls

Impl

emen

ted

in s

ix o

f nin

e st

ates

, inv

olvi

ng

abou

t 100

0 G

Ps

(201

4); t

hree

sta

tes

do n

ot

curr

ently

pro

vide

The

rapi

e ak

tiv b

ut o

ffer

diab

etes

edu

catio

n pr

ogra

mm

es

Abo

ut 3

9 50

0 pa

tient

s en

rolle

d inDMPacrossthefivestates

that

hav

e im

plem

ente

d Th

erap

ie

aktiv

(18%

of a

ll pe

ople

with

type

2

diab

etes

) (20

14)

Inte

grat

ed s

trok

e ca

re, U

pper

A

ustr

ia

Reg

iona

l SH

I fun

d U

pper

A

ustr

ia a

nd U

pper

Aus

tria

he

alth

fund

(50%

eac

h)

Notspecified

Not

app

licab

leIm

plem

ente

d ac

ross

Upp

er A

ustr

ia a

nd

invo

lvin

g al

l hos

pita

ls th

at p

rovi

de a

cute

st

roke

car

e, m

edic

al e

mer

genc

y se

rvic

es

and

thre

e re

habi

litat

ion

cent

res;

tran

sfer

red

into

rout

ine

care

from

the

end

of 2

010

Ther

e ar

e no

pub

lishe

d da

ta o

n th

e nu

mbe

r of

str

oke

patie

nts

whohavebenefitedfrom

the

prog

ram

me

so fa

r

Car

e co

ordi

natio

n/in

terfa

ce

man

agem

ent

Sty

ria

Reg

iona

l SH

I fun

d S

tyria

; Gra

z m

odel

als

o su

ppor

ted

by S

tyria

hea

lth

fund

(200

9)

Not

app

licab

leN

ot a

pplic

able

Intr

oduc

ed a

s pi

lot p

roje

ct in

one

loca

lity,

th

e ap

proa

ch w

as g

radu

ally

ext

ende

d ac

ross

Sty

ria; G

raz

mod

el to

be

tran

sfer

red

into

usu

al c

are

Ther

e ar

e no

pub

lishe

d da

ta o

n th

e nu

mbe

r of

pat

ient

s co

vere

d by

the

prog

ram

me

Am

bula

tory

afte

r-ca

re o

f str

oke

patie

nts,

Sal

zbur

g

Sal

zbur

g he

alth

fund

(9

5%) p

lus

3% p

atie

nt c

o-pa

ymen

t (de

duct

ible

for

hom

e vi

sit)

Not

app

licab

leN

ot a

pplic

able

Ser

vice

prin

cipa

lly a

cces

sibl

e to

all

stro

ke

patie

nts

acro

ss L

and

Sal

zbur

g; la

ck o

f th

erap

ists

in re

mot

e ar

eas

redu

ces

acce

ss

In 2

009,

the

serv

ice

cove

red

appr

oxim

atel

y 45

0 pa

tient

s w

ho

can

acce

ss s

ervi

ce o

n re

ferr

al

only

Kar

diom

obil

– H

ome

care

for

patie

nts

with

ch

roni

c he

art

failu

re

Reg

iona

l SH

I fun

d an

d La

nd S

alzb

urg

at a

bout

50

% e

ach

Not

app

licab

leN

ot a

pplic

able

Program

mecomprisesfivetrainednurses

oper

atin

g ac

ross

Lan

d S

alzb

urg

Acc

ess

to th

e se

rvic

e is

thro

ugh

refe

rral

; the

re a

re n

o pu

blis

hed

data

on

the

num

ber

of p

atie

nts

cove

red

Den

mar

k

SIK

S p

roje

ct –

In

tegr

ated

effo

rt

for

peop

le li

ving

w

ith c

hron

ic

dise

ase

Com

bina

tion

of u

sual

so

urce

s an

d go

vern

men

t gr

ant f

or 2

005–

2007

pr

ojec

t per

iod;

full

fund

ing

from

usu

al s

ourc

es fr

om

2007

Not

app

licab

leN

etw

orki

ng a

nd

peer

pre

ssur

e th

roug

h st

eerin

g co

mm

ittee

, pro

ject

gr

oup

and

wor

king

gr

oups

thro

ugho

ut

proj

ect p

erio

d

Impl

emen

ted

as a

pilo

t pro

ject

in th

e Ø

ster

bro

heal

th c

are

cent

re a

nd B

ispe

bjer

g ho

spita

l in

Cop

enha

gen

for

a pe

riod

of

thre

e ye

ars;

sub

sequ

ently

a p

art o

f DM

P

for

CO

PD

, typ

e 2

diab

etes

and

CV

D in

the

Cap

ital R

egio

n of

Den

mar

k

Dur

ing

2005

–200

7, a

bout

70

0 pa

tient

s pa

rtic

ipat

ed

in th

e S

IKS

pro

ject

; acc

ess

is th

roug

h re

ferr

al fo

llow

ing

diag

nosi

s (a

ppro

xim

atel

y 90

%

of p

artic

ipat

ing

phys

icia

ns re

fer

patie

nts

on)


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Den

mar

k co

ntd

Reg

iona

l dis

ease

m

anag

emen

t pr

ogra

mm

es

Cen

tral

gov

ernm

ent

fund

ing

pool

for

the

deve

lopm

ent o

f DM

Ps

of

DK

K 4

38 m

illion

dur

ing

2010

-201

2

Not

pla

nned

Notspecified

DM

Ps

for

CO

PD

and

type

2 d

iabe

tes,

CV

D,

dem

entia

and

mus

culo

skel

etal

dis

orde

rs

impl

emen

ted

in C

apita

l Reg

ion

(end

201

0);

DM

Ps

for

CO

PD

, typ

e 2

diab

etes

, CV

D,

depr

essi

on a

nd lo

wer

-bac

k pa

in d

evel

oped

in

the

Cen

tral

Den

mar

k R

egio

n; D

MP

s fo

r C

OP

D, t

ype

2 di

abet

es, C

VD

and

ske

leta

l di

sord

ers

deve

lope

d an

d, fr

om 2

010,

im

plem

ente

d in

sou

ther

n D

enm

ark;

DM

Ps

for

CO

PD

, typ

e 2

diab

etes

, dem

entia

, sc

hizo

phre

nia

and

back

pro

blem

s de

velo

ped

in R

egio

n Ze

elan

d

It is

ant

icip

ated

that

the

prog

ram

mes

will

cove

r al

l ta

rget

ed p

atie

nts

acro

ss th

e co

untr

y

Inte

grat

ed c

linic

al

path

way

sFu

nded

from

usu

al

sour

ces

(taxa

tion)

Not

app

licab

leNotspecified

As

a na

tiona

l pro

gram

me,

inte

grat

ed

clin

ical

pat

hway

s ar

e im

plem

ente

d ac

ross

D

enm

ark

It is

ant

icip

ated

that

the

inte

grat

ed c

linic

al p

athw

ays

will

cove

r ap

prox

imat

ely

40 0

00

CV

D p

atie

nts

per

year

and

all

canc

er p

atie

nts

Eng

land

Cas

e m

anag

emen

t/co

mm

unity

mat

ron

Fund

ed fr

om u

sual

so

urce

s w

ithin

the

NH

SN

oNotspecified

2004

pol

icy

fore

saw

impl

emen

tatio

n of

ca

se m

anag

emen

t and

app

oint

men

t of

3000

com

mun

ity m

atro

ns b

y al

l PC

Ts in

20

07; t

here

are

now

bet

wee

n 62

0 an

d 13

50 c

omm

unity

mat

rons

In p

rinci

ple,

all

NH

S p

atie

nts

in

Eng

land

sho

uld

have

acc

ess

to

com

mun

ity m

atro

n se

rvic

es

Qua

lity

and

outc

omes

fra

mew

ork

(QO

F)

Fund

ed fr

om u

sual

so

urce

s w

ithin

the

NH

SYe

s: a

war

d of

ac

hiev

emen

t po

ints

for

prac

tices

de

mon

stra

ting

that

they

hav

e m

et

seve

ral s

tage

s in

th

e m

anag

emen

t of

a g

iven

, usu

ally

ch

roni

c co

nditi

on, f

or

a pr

opor

tion

of th

e re

leva

nt p

opul

atio

n

Pee

r pr

essu

re:

perfo

rman

ce re

sults

ar

e pu

blis

hed

by

the

Hea

lth &

Soc

ial

Car

e In

form

atio

n C

entr

e

Volu

ntar

y fo

r G

P p

ract

ices

; mos

t pra

ctic

es

have

join

ed. C

urre

ntly,

mor

e th

an 8

000

prac

tices

hav

e si

gned

up

to th

e sc

hem

es,

cove

ring

som

e 54

milli

on p

eopl

e in

Eng

land

The

sche

me

initi

ally

app

lied

to

acro

ss th

e U

nite

d K

ingd

om a

nd

prin

cipa

lly c

over

s al

l pat

ient

s re

gist

ered

with

a g

iven

pra

ctic

e pa

rtic

ipat

ing

in th

e sc

hem

e; fr

om

2013

, QO

F ha

s di

ffere

d ac

ross

th

e fo

ur c

ount

ries

of th

e U

nite

d K

ingd

om

Table

3.4

con

td


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Eng

land

con

td

Par

tner

ship

for

olde

r pe

ople

pr

ojec

t (P

OP

P)

Ser

vice

s de

liver

ed b

y pi

lots

fund

ed fr

om u

sual

so

urce

s (h

ealth

ser

vice

s:

NH

S; s

ocia

l ser

vice

s: lo

cal

auth

oriti

es)

Gov

ernm

ent g

rant

to

supp

ort p

ilot s

et-u

pR

ecog

nitio

n as

a

gove

rnm

ent-

spon

sore

d pi

lot s

ite

PO

PP

ran

a to

tal o

f 146

pro

ject

s in

volv

ing

522

orga

niza

tions

incl

udin

g th

e po

lice

and

hous

ing

asso

ciat

ions

; 85%

of p

roje

cts

secu

red

fund

ing

beyo

nd th

e pi

lot p

hase

in

to u

sual

car

e

Aro

und

264

000

peop

le w

ere

cove

red

by th

e se

rvic

es p

rovi

ded

by p

roje

cts

Inte

grat

ed c

are

pilo

tsS

ervi

ces

deliv

ered

by

pilo

ts fu

nded

from

usu

al

sour

ces

(hea

lth s

ervi

ces:

N

HS

; soc

ial s

ervi

ces:

loca

l au

thor

ities

)

Gov

ernm

ent g

rant

to

supp

ort p

ilot s

et-u

p (g

rant

s of

bet

wee

n G

BP

600

000

and

GB

P3.

9 m

illion

per

si

te o

ver

two

year

s)

Rec

ogni

tion

as

a go

vern

men

t-sp

onso

red

pilo

t site

The

pilo

t pro

gram

me

invo

lved

16

Prim

ary

care

trus

tsP

opul

atio

n co

vera

ge o

f sch

emes

va

ried;

acc

ess

to s

ervi

ces

limite

d to

(tar

get)

popu

latio

ns in

pilo

t si

tes

Est

onia

Qua

lity

man

agem

ent i

n pr

imar

y he

alth

ca

re

Fund

ed fr

om u

sual

so

urce

s (E

HIF

); ad

ditio

nal

fund

ing

with

in q

ualit

y m

anag

emen

t fra

mew

ork

for

diab

etes

/CV

D c

are

Targ

eted

at G

P

prac

tices

with

in

qual

ity m

anag

emen

t fra

mew

ork

Net

wor

king

am

ong

prov

ider

sQ

ualit

y m

anag

emen

t fra

mew

ork

for

diab

etes

and

chr

onic

CV

D im

plem

ente

d ac

ross

Est

onia

and

cov

erin

g al

l GP

pr

actic

es

Prin

cipa

lly, a

ll pe

rson

s w

ith

diab

etes

/chr

onic

CV

D a

re

cove

red

by v

irtue

of S

HI;

acce

ss

to c

are

is fr

ee o

f cha

rge

Chr

onic

dis

ease

m

anag

emen

t at

the

prim

ary/

seco

ndar

y ca

re

inte

rface

Fund

ed fr

om u

sual

so

urce

s; a

dditi

onal

fundingforParkinson’s

asso

ciat

ion

for

patie

nt

educ

atio

n an

d su

ppor

t

Not

app

licab

leN

etw

orki

ng a

mon

g pr

ovid

ers

Impl

emen

ted

acro

ss E

ston

ia a

s pa

rt o

f us

ual c

are

Prin

cipa

lly, a

ll pe

rson

s w

ith

diag

nose

d di

seas

e co

vere

d by

vi

rtue

of S

HI;

acce

ss to

car

e is

fre

e of

cha

rge

Fran

ceP

rovi

der

netw

orks

Fo

r ex

ampl

e,

diab

etes

net

wor

ks:

RE

VE

SD

IAB

FIQ

CS

fund

est

ablis

hed

by 2

007

heal

th re

form

Fees

for

vario

us

prov

ider

s in

the

netw

ork,

for

exam

ple,

GP

s (a

nnua

l ass

essm

ent),

ed

ucat

ion,

die

titia

ns

Free

acc

ess

for

patie

nts

to c

erta

in

serv

ices

that

wou

ld

othe

rwis

e ha

ve

to p

ay fo

r (fo

r ex

ampl

e, fo

ot c

are)

RE

VE

SD

IAB

is b

ased

in th

ree

depa

rtm

ents

(d

épar

tmen

ts) i

n th

e P

aris

regi

on, i

nvol

ving

, in

200

7–20

08, a

roun

d 50

0 he

alth

pr

ofes

sion

als

in th

e E

sson

ne d

epar

tmen

t; O

vera

ll, in

200

7, th

ere

wer

e 72

dia

bete

s ne

twor

ks, i

nvol

ving

14

000

heal

th

prof

essi

onal

s

RE

VE

SD

IAB

is b

ased

in th

e P

aris

regi

on c

over

ing

abou

t 30

00 p

atie

nts

with

dia

bete

s;

over

all,

in 2

007,

aro

und

60 0

00

peop

le w

ith d

iabe

tes

wer

e en

rolle

d in

dia

bete

s ne

twor

ks

(app

roxi

mat

ely

2.5%

of d

iabe

tic

patie

nts

in F

ranc

e)


Nam

eFu

ndin

gU

se o

f fi

nanc

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ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

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ceP

rovi

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netw

orks

con

tdFo

r ex

ampl

e,

Coo

rdin

atio

n of

pr

ofes

sion

al c

are

for

the

elde

rly

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PA)

FIQ

CS

fund

est

ablis

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by th

e 20

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ealth

refo

rmNotspecified

Notspecified

The

netw

ork

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stab

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Par

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and

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invo

lved

79

out

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00 p

rimar

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re p

hysi

cian

s pr

actis

ing

in th

e ar

ea

By

the

end

of 2

007,

ap

prox

imat

ely

250

olde

r pe

ople

ha

d be

en re

ferr

ed to

CO

PA;

it is

bei

ng im

plem

ente

d in

ot

her

part

s of

Par

is a

nd th

ere

is in

tere

st in

oth

er re

gion

s of

Fr

ance

and

Bel

gium

als

o

Specificprogram

mes

Sop

hia

diab

etes

an

d as

thm

a ca

re

prog

ram

me

Fund

ed fr

om u

sual

so

urce

s (S

tatu

tory

hea

lth

insu

ranc

e (C

NA

M)

GP

s in

volv

ed a

re

paid

EU

R 6

6 pe

r pa

tient

per

yea

r

Pro

vide

s pa

tient

s w

ith fr

ee a

cces

s to

tele

phon

e-ba

sed

inte

rven

tion

by tr

aine

d nu

rse

follo

win

g en

rolm

ent

with

SH

I fun

d

Exp

erim

enta

l pha

se ta

rget

ed p

atie

nts

of 6

000

GP

s (6

.4%

of a

ll G

Ps)

in 1

0 de

part

men

ts; e

xpan

ded

in 2

010

to re

ach

17 5

00 G

Ps

in 1

9 de

part

men

ts; r

oll-o

ut

acro

ss F

ranc

e in

201

3

Exp

erim

enta

l pha

se a

imed

at

reac

hing

136

000

pat

ient

s w

ith d

iabe

tes;

by

the

end

of 2

010,

62

000

had

join

ed

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roxi

mat

ely

2.5%

of a

ll pe

ople

with

dia

bete

s)

Hea

lth A

ctio

n by

Te

ams

of S

elf-

Em

ploy

ed H

ealth

P

rofe

ssio

nals

(A

SA

LEE

)

UR

CA

M (r

egio

nal S

HI

fund

); us

ual s

ourc

esN

oP

rofe

ssio

nal

mot

ivat

ion

(pro

ject

w

as s

et u

p by

loca

l G

Ps)

ASALE

Eisanon-profitorganizationwhich,

as o

f 200

7, b

roug

ht to

geth

er 4

1 G

Ps

and

eigh

t nur

ses

in 1

8 G

P p

ract

ices

The

proj

ect c

over

ed a

roun

d 15

00 p

atie

nts

Hos

pita

l dis

char

ge

prog

ram

for

hear

t fa

ilure

pat

ient

s (P

RA

DO

)

Fund

ed fr

om u

sual

so

urce

s (S

tatu

tory

hea

lth

insu

ranc

e (C

NA

M)

GP

s au

thor

ized

to b

ill a

long

con

sulta

tion

for

coor

dina

tion

effo

rts

Ded

icat

ed tr

aini

ng

for

hom

e fo

llow

-up

by n

urse

s

Pilotp

haseinfivedepartm

ents

The

pilo

t pha

ses

conc

erns

an

estim

ated

60

000

patie

nts

per

year

Specificpayment

base

d on

pub

lic

heal

th o

bjec

tives

(R

OS

P)

Sta

tuto

ry h

ealth

insu

ranc

e (C

NA

M)

Yes:

add

ition

al

rem

uner

atio

n ta

kes

into

acc

ount

the

popu

latio

n si

ze a

nd

29 q

ualit

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dica

tors

w

ith in

term

edia

te

andfinaltargets

Phy

sici

ans

can

follo

w th

e ev

olut

ions

of t

heir

qual

ity in

dica

tors

on

a d

edic

ated

w

ebsi

te

Volu

ntar

y pa

rtic

ipat

ion

In 2

012,

mor

e th

an 7

5 00

0 ph

ysic

ians

par

ticip

ated

in th

e pr

ogra

mm

e, re

pres

entin

g a

maj

ority

of e

ligib

le G

Ps

Table

3.4

con

td


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

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Up

take

Fran

ce c

ontd

Mea

sure

s of

the

2003

–200

7 C

ance

r P

lan

Pro

toco

l fo

r di

seas

e co

mm

unic

atio

n an

d pr

omot

ion

of

shar

ed d

ecis

ion-

mak

ing

(Dis

posi

tif

d’annonce)

Fund

ed fr

om re

gion

al

budg

ets

with

in M

IGA

C

envelope(specificbudget

tofinanceactivitiesof

publ

ic u

tility

) as

part

of

usu

al c

are

(hos

pita

l re

imbu

rsem

ent)

with

in S

HI

Som

e re

gion

s su

pple

men

t us

ual p

aym

ent t

o ph

ysic

ians

for

time

dedi

cate

d to

pat

ient

s w

ithin

dis

posi

tif

d’annonce

Net

wor

king

ha

s be

en m

ade

oblig

ator

y fo

r th

e m

anag

emen

t of

canc

er p

atie

nts

As

part

of t

he n

atio

nal C

ance

r P

lan,

pr

inci

pally

rolle

d ou

t acr

oss

the

coun

try

with

in th

e tim

e fra

me

of th

e 20

03–2

007

Can

cer

Pla

n; b

y 20

06, o

nly

half

of th

e fu

nds

set a

side

by

regi

ons

had

been

use

d fo

r th

is p

urpo

se a

nd a

cces

sibl

e to

all

new

ly

diag

nose

d ca

ncer

pat

ient

s

By

2007

, mor

e th

an 9

2 00

0 pa

tient

s ha

d be

en s

uppo

rted

th

roug

h a

dedi

cate

d di

spos

itif

d’annonce(app

roximately30%

of a

ll pa

tient

s ne

wly

dia

gnos

ed

with

can

cer);

app

roxi

mat

ely

23 0

00 h

ad re

ceiv

ed a

pe

rson

aliz

ed c

are

prog

ram

me

(PP

S) (

appr

oxim

atel

y 7%

of

patie

nts)

Mul

tidis

cipl

inar

y te

am m

eetin

g (R

CP

)

Fund

ed fr

om re

gion

al

budg

ets

with

in th

e M

IGA

C

envelope(specificbudget

tofinanceactivitiesof

publ

ic u

tility

) as

part

of

usu

al c

are

(hos

pita

l re

imbu

rsem

ent)

with

in S

HI

Notspecified

Notspecified

As

part

of t

he n

atio

nal C

ance

r P

lan,

pr

inci

pally

rolle

d ou

t acr

oss

the

coun

try

with

in ti

me

fram

e of

200

3–20

07 C

ance

r P

lan

and

acce

ssib

le to

all

new

ly d

iagn

osed

ca

ncer

pat

ient

s

By

2007

, app

roxi

mat

ely

500

000

RC

Ps

had

been

re

cord

ed w

hile

the

num

ber

of n

ewly

dia

gnos

ed c

ance

r pa

tient

s w

as 3

45 0

00 (p

artly

reflectingrepeatRCPforsome

patie

nts

pre/

post

-tre

atm

ent);

ap

prox

imat

ely

45%

of c

ance

r ca

ses

wer

e re

cord

ed b

y R

CP

s

Reg

iona

l can

cer

netw

orks

FIQ

CS

fund

est

ablis

hed

by 2

007

heal

th re

form

Notspecified

Net

wor

king

ha

s be

en m

ade

oblig

ator

y fo

r th

e m

anag

emen

t of

canc

er p

atie

nts;

po

ssib

ility

of

prov

ider

mon

itorin

g th

roug

h E

EP

As

part

of t

he n

atio

nal C

ance

r P

lan

rolle

d ou

t acr

oss

the

coun

try

with

in th

e tim

e fra

me

of th

e 20

03–2

007

Can

cer

Pla

n an

d ac

cess

ible

to a

ll ca

ncer

pat

ient

s

Not

kno

wn


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Fran

ceM

easu

res

of th

e 20

03–2

007

Can

cer

Pla

n co

ntd

Loca

l can

cer

or

loca

l mul

tiple

pa

thol

ogy

netw

orks

GP

s an

d nu

rses

fund

ed

from

usu

al s

ourc

es

with

in S

HI;

netw

orks

fu

nded

thro

ugh

FIQ

CS

es

tabl

ishe

d by

the

2007

he

alth

refo

rm

Phy

sici

ans:

pos

sibi

lity

to re

ceiv

e ad

ditio

nal

reim

burs

emen

t fo

r tim

e/ex

pert

ise

dedi

cate

d to

can

cer

patie

nts;

Pat

ient

s:

maybenefitfrom

financialsuppo

rt

for

hous

ehol

d as

sist

ance

Net

wor

king

ha

s be

en m

ade

oblig

ator

y fo

r th

e m

anag

emen

t of

canc

er p

atie

nts;

po

ssib

ility

of

prov

ider

mon

itorin

g th

roug

h E

EP

As

part

of t

he n

atio

nal C

ance

r P

lan,

pr

inci

pally

rolle

d ou

t acr

oss

the

coun

try

with

in th

e tim

e fra

me

of th

e 20

03–2

007

Can

cer

Pla

n an

d ac

cess

ible

to a

ll ca

ncer

pa

tient

s

Not

kno

wn

Ger

man

y

Dis

ease

m

anag

emen

t pr

ogra

mm

es

Fund

ed fr

om u

sual

so

urce

s (S

HI)

DM

P p

hysi

cian

s:

addi

tiona

l pay

men

t fo

r do

cum

enta

tion,

ed

ucat

ion

Free

acc

ess

for

part

icip

atin

g pa

tient

s to

ed

ucat

ion

clas

ses

and

mat

eria

ls;

phys

icia

ns: p

eer

pres

sure

; SH

I fun

ds

lega

lly re

quire

d to

of

fer

DM

P

DM

Ps

are

offe

red

by S

HI f

unds

acr

oss

Ger

man

y; in

201

3 th

ere

wer

e 17

00–1

800

DM

Ps

for

each

con

ditio

n; th

e nu

mbe

r of

par

ticip

atin

g ph

ysic

ians

var

ies,

ap

prox

imat

ely

65%

GP

s ac

t as

DM

P

phys

icia

n fo

r ty

pe 2

dia

bete

s (5

7% fo

r C

HD

)

By

the

end

of 2

013,

a to

tal

of 6

.4 m

illion

indi

vidu

als

wer

e en

rolle

d in

one

or

mor

e D

MP

s,

from

122

214

in b

reas

t can

cer

DM

P to

app

roxi

mat

ely

3.8

milli

on in

type

2 d

iabe

tes

DM

P

GP

con

trac

tsP

rinci

pally

from

usu

al

sour

ces

(SH

I) bu

t with

co

ntra

ct a

rran

gem

ents

perm

ittingflexible

GP

pay

men

t diff

eren

t fro

m u

sual

car

e G

P

reim

burs

emen

t

GP

s: a

dditi

onal

pa

ymen

t for

asp

ects

su

ch a

s qu

ality

im

prov

emen

t and

ra

tiona

l pre

scrib

ing.

P

atie

nts:

exe

mpt

ion

from

pra

ctic

e fe

e

GP

s: P

eer

pres

sure

in

som

e re

gion

s;

SH

I fun

ds le

gally

re

quire

d to

offe

r G

P

cont

ract

s

By

the

end

of 2

007,

55

GP

con

trac

ts h

ad

been

con

clud

ed w

ith G

P p

artic

ipat

ion

vary

ing

amon

g re

gion

s; m

ore

rece

nt d

ata

are

not d

ocum

ente

d

Pro

port

ion

of S

HI i

nsur

ed

peop

le e

nrol

led

varie

s be

twee

n 5.

9 m

illion

(8.5

% o

f all

SH

I in

sure

d) in

200

7 to

19%

in 2

010

Table

3.4

con

td


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Ger

man

y co

ntd

Inte

grat

ed c

are:

H

ealth

y K

inzi

gtal

Prin

cipa

lly fu

nded

fro

m u

sual

sou

rces

(S

HI)

but w

ith c

ontr

act

arra

ngem

ents

per

mitt

ing

flexiblereimbursem

ent;

star

t-up

fund

s (ti

me-

limite

d to

end

of 2

008)

Phy

sici

an

reim

burs

emen

t in

volv

es p

ay-f

or-

perfo

rman

ce (P

4P)

elem

ent

Phy

sici

ans:

ne

twor

king

; pa

tient

s: a

cces

s to

free

che

ck-

ups,

pre

vent

ion/

trea

tmen

t pla

ns,

case

con

fere

nces

w

ith s

peci

alis

ts,

etc.

By

the

end

of 2

008,

app

roxi

mat

ely

6400

in

tegr

ated

car

e co

ntra

cts

had

been

co

nclu

ded;

con

tent

and

sco

pe v

arie

s w

idel

y an

d th

eir

num

ber

has

stag

nate

d si

nce;

Hea

lthy

Kin

zigt

al in

volv

es o

ver

90

prov

ider

s (5

2% o

f all

prov

ider

s in

the

regi

on

in 2

013)

By

the

end

of 2

008,

ap

prox

imat

ely

4 m

illion

SH

I m

embe

rs w

ere

enro

lled

with

an

inte

grat

ed c

are

cont

ract

(a

ppro

xim

atel

y 6%

of a

ll S

HI

insu

red)

; Hea

lthy

Kin

zigt

al

cove

rs o

ver

9000

peo

ple

(30%

of

the

rele

vant

SH

I mem

bers

in

the

regi

on) (

2013

)

Com

mun

ity

nurs

es: c

are

assi

stan

t in

fam

ily

prac

tice

(Ver

AH

)

Prin

cipa

lly fu

nded

from

us

ual s

ourc

es (S

HI)

with

in

GP

con

trac

ts

GP

s: s

ervi

ces

prov

ided

by

prac

tice

assi

stan

ts

reim

burs

able

thro

ugh

SH

I

Pra

ctic

e as

sist

ant:

prof

essi

onal

de

velo

pmen

t

Inco

rpor

ated

in s

elec

ted

GP

mod

els,

see

ab

ove

Inco

rpor

ated

in s

elec

ted

GP

m

odel

s, s

ee a

bove

Hun

gary

Trea

tmen

t (andfinancing)

prot

ocol

s

Fund

ed fr

om u

sual

so

urce

s (S

HI)

No

Notspecified

As

part

of t

he m

ain

syst

em, c

over

age,

in

prin

cipl

e, is

100

%. I

n pr

actic

e, th

e ad

here

nce

to tr

eatm

ent p

roto

cols

is r

arel

y au

dite

d

In p

rinci

ple,

all

diag

nose

d pa

tient

s sh

ould

be

cove

red

by

trea

tmen

t pro

toco

ls; a

cces

s is

lik

ely

to v

ary

acro

ss re

gion

s,

reflectinginequalitiesinoverall

acce

ss to

car

e

Car

e co

ordi

natio

n pi

lot

Prin

cipa

lly fu

nded

from

us

ual s

ourc

es (S

HI);

ad

ditio

nal f

undi

ng fo

r ad

min

istr

ativ

e co

sts

and

prev

entio

n pr

ogra

mm

es

(cap

itatio

n fo

r ca

re

coor

dina

tor)

Phy

sici

ans:

ris

k sh

arin

g w

ith s

avin

gs

achi

eved

at e

nd

offinancialyear

redi

strib

uted

to

prov

ider

s

Pro

vide

rs:

peer

pre

ssur

e;

netw

orki

ng

The

CC

P g

radu

ally

exp

ande

d fro

m n

ine

care

coo

rdin

ator

s in

199

9 to

16

care

co

ordi

nato

rs in

200

5 w

hen

1500

GP

pr

actic

es p

artic

ipat

ed; e

stab

lishe

d in

the

Vere

segy

ház

regi

on, t

he C

CP

was

clo

sed

dow

n in

200

8

Gra

dual

exp

ansi

on o

f the

pr

ojec

t cov

erin

g 16

0 00

0 re

side

nts

in th

e re

gion

of

Vere

segy

ház

in 1

999

to 2

milli

on

in 2

005


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Hun

gary

con

tdM

ultif

unct

iona

l co

mm

unity

ce

ntre

s

Prin

cipa

lly fu

nded

fro

m u

sual

sou

rces

; in

frast

ruct

ure

inve

stm

ents

fro

m E

urop

ean

Uni

on

fund

s; a

dditi

onal

fund

ing

from

loca

l gov

ernm

ent

dete

rmin

ed b

y se

rvic

es

prov

ided

Notspecified

Notspecified

Pro

gram

me

impl

emen

tatio

n is

ong

oing

; it i

s an

ticip

ated

that

50–

60 c

entr

es/p

roje

cts

will

be e

stab

lishe

d

Cen

tres

are

not

yet

in o

pera

tion;

it

is a

ntic

ipat

ed th

at 3

0–35

%

of s

mal

l reg

ions

, and

thei

r re

side

nts,

will

be c

over

ed b

y th

e pr

ogra

mm

e

Ast

hma

dise

ase

man

agem

ent

prog

ram

me

Prin

cipa

lly fu

nded

from

us

ual s

ourc

es w

ith n

urse

tr

aini

ng a

nd p

aym

ent a

s w

ell a

s eq

uipm

ent (

for

exam

ple,

spi

rom

eter

for

patie

nts)

and

prin

ted

mat

eria

ls fu

nded

by

pha

rmac

eutic

al

com

pani

es

Nur

se p

aym

ent

is c

over

ed b

y ph

arm

aceu

tical

co

mpa

nies

Notspecified

The

prog

ram

me

has

evol

ved

into

a fo

rmal

na

tiona

l net

wor

k of

ast

hma

nurs

es. B

y Ja

nuar

y 20

10, t

here

wer

e ar

ound

850

tr

aine

d as

thm

a nu

rses

acr

oss

Hun

gary

; th

e nu

mbe

r of

pul

mon

ary

disp

ensa

ries

is

arou

nd 1

60 (2

007)

Pre

cise

dat

a on

pop

ulat

ion

cove

rage

are

lack

ing;

in th

eory

th

e co

vera

ge s

houl

d be

100

%

Dia

bete

s ca

re

man

agem

ent

prog

ram

me

Prin

cipa

lly fu

nded

fro

m u

sual

sou

rces

w

ith p

harm

aceu

tical

an

d m

edic

al d

evic

es

com

pani

es c

over

ing

extr

a co

sts

incl

udin

g pa

ymen

t to

doct

ors

and

nurs

es, e

quip

men

t and

op

erat

iona

l cos

ts

Dia

bete

s sp

ecia

list

paym

ents

cov

ered

by

pha

rmac

eutic

al/

devi

ce c

ompa

nies

Notspecified

Ext

ent t

o w

hich

pro

gram

me

has

been

im

plem

ente

d by

spe

cial

ist d

iabe

tes

outp

atie

nt u

nits

is n

ot w

ell u

nder

stoo

d; in

20

08, t

here

wer

e 17

6 sp

ecia

list d

iabe

tes

units

, inc

ludi

ng 4

1 in

Bud

apes

t

App

roxi

mat

ely

20 0

00

patie

nts

with

type

2 d

iabe

tes

in B

udap

est a

re c

over

ed b

y ap

prox

imat

ely

40 s

peci

alis

t di

abet

es o

utpa

tient

uni

ts; n

ot

all u

nits

pro

vide

all

prog

ram

me

com

pone

nts

Italy

Inte

grat

ion,

m

anag

emen

t and

as

sist

ance

for

diab

etes

(IG

EA

)

Fund

ed fr

om u

sual

so

urce

s (S

SN

), co

mpl

emen

ted

by

natio

nal a

nd re

gion

al

fund

s ea

rmar

ked

for

prev

entio

n

Use

of i

ncen

tives

for

GP

s to

par

ticip

ate

varie

s am

ong

regi

ons

Phy

sici

ans:

ne

twor

king

, in

form

atio

n sh

arin

g, a

cces

s to

gu

idel

ines

, pee

r pr

essu

re

Impl

emen

tatio

n at

regi

onal

leve

l has

be

en a

gra

dual

pro

cess

; 35%

of G

P

prac

tices

in P

iedm

ont p

artic

ipat

e (2

009)

; as

a g

over

nmen

t-sp

onso

red

prog

ram

me

invo

lvem

ent o

f all

GP

s an

ticip

ated

Bec

ause

of g

radu

al

impl

emen

tatio

n of

the

prog

ram

me,

pat

ient

enr

olm

ent

is o

ngoi

ng; t

here

are

no

prec

ise

figuresontheprop

ortionofthe

popu

latio

n co

vere

d by

IGE

A

Table

3.4

con

td


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Italy

con

td“F

rom

On-

Dem

and

to

Pro

activ

e P

rimar

y C

are”

pro

gram

me,

Tu

scan

y

Fund

ed fr

om u

sual

so

urce

s (S

SN

) with

re

gion

al re

gula

tion

stip

ulat

ing

allo

catio

n of

reso

urce

s to

pro

ject

im

plem

enta

tion

of E

UR

8

883

000

over

of t

hree

ye

ars

GP

s: in

cent

ive

paym

ent d

epen

ding

on

leve

l of

invo

lvem

ent (

team

le

ad; p

artic

ipan

t) an

d ag

ains

t per

form

ance

(P

4P)

GP

: pro

gram

me

supp

orte

d by

Tuscany’sGP

asso

ciat

ion,

th

us c

reat

ing

peer

pre

ssur

e to

pa

rtic

ipat

e

Two-

stag

e im

plem

enta

tion:

initi

al p

hase

in

201

0 in

volv

ed th

e es

tabl

ishm

ent o

f ap

prox

imat

ely

50 m

odul

es w

ith a

dditi

on o

f m

odul

es o

ngoi

ng; f

urth

er im

plem

enta

tion

ongo

ing

App

roxi

mat

ely

50 m

odul

es

cove

r ap

prox

imat

ely

500

000

resi

dent

s; in

itial

ly ta

rget

ing

diab

etes

and

hea

rt fa

ilure

; ot

her

cond

ition

s to

be

adde

d;

expe

cted

cov

erag

e w

ith fu

ll im

plem

enta

tion:

1.1

milli

on w

ith

chro

nic

dise

ase

in T

usca

ny

Leon

ardo

pilo

t pr

ojec

t, P

uglia

Fund

ed jo

intly

by

regi

onal

fund

s, M

inis

try

of H

ealth

Spe

cial

P

rogr

amm

es fu

nd,

loca

l hea

lth s

yste

m a

nd

PfizerItaly(contributing

Info

rmaC

are™

sof

twar

e)

GP

s: lu

mp

sum

at

pro

ject

sta

rt,

to in

cent

iviz

e pa

rtic

ipat

ion,

plu

s va

riabl

e pa

ymen

t at

the

end,

bas

ed o

n pe

rform

ance

Notspecified

Tota

l of 8

5 G

Ps

in P

uglia

regi

on

(app

roxi

mat

ely

2.5%

of G

Ps

prac

tisin

g in

th

e re

gion

), w

orki

ng w

ith s

ome

30 c

are

man

ager

s

Pro

ject

cov

ered

just

und

er 1

160

patie

nts

for

a pr

ojec

t dur

atio

n of

18

mon

ths

at th

e Le

cce

AS

L

Raf

fael

lo p

roje

ct,

Mar

che

and

Abr

uzzo

Join

tly fu

nded

by

regi

onal

fu

nds

allo

cate

d to

hea

lth

care

; add

ition

al fu

nds

by

Min

istr

y of

Hea

lth S

peci

al

Pro

gram

mes

fund

and

cofinancingbyPfizerItaly

Fina

ncia

l inc

entiv

es

for

GP

s pa

rtic

ipat

ing

in th

e pr

ojec

t (no

t furtherspecified)

Notspecified

The

rese

arch

pro

ject

invo

lves

16

clus

ters

of

GP

s pa

rtic

ipat

ing

in th

e ex

perim

enta

l arm

of

the

stud

y

The

rese

arch

pro

ject

is li

mite

d toadefinedgroupofpatients

recr

uite

d fo

r pa

rtic

ipat

ion,

a

tota

l of 9

00 p

atie

nts

in th

e re

gion

s of

Mar

che

and

Abr

uzzo

Latv

ia

Gen

eral

prim

ary

heal

th c

are

syst

emFu

nded

from

usu

al

sour

ces

(taxa

tion)

Notspecified

Notspecified

Chr

onic

dis

ease

man

agem

ent e

mbe

dded

w

ithin

prim

ary

care

and

as

such

invo

lves

al

l GP

s; a

201

0 ev

alua

tion

of th

e pr

imar

y ca

re s

yste

m fo

und

low

leve

ls o

f qua

lity

of c

hron

ic c

are

as a

sses

sed

by re

gula

r ex

amin

atio

n of

pat

ient

s w

ith ty

pe 2

di

abet

es (2

5% o

f all

GP

s) o

r as

thm

a (5

%)

Chr

onic

dis

ease

man

agem

ent

embe

dded

with

in p

rimar

y ca

re a

nd th

eref

ore

cove

ring

virt

ually

the

entir

e po

pula

tion;

severefinancialpressures

have

, how

ever

, mea

nt th

at

appr

oxim

atel

y 45

% o

f the

po

pula

tion

cann

ot a

cces

s se

rvic

es b

ecau

se o

f req

uire

d co

-pay

men

ts (2

008)


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Lith

uani

a

Impr

ovin

g in

ters

ecto

ral

colla

bora

tion

Fund

ed fr

om u

sual

so

urce

s (S

HI),

soc

ial

care

fund

ed b

y lo

cal

gove

rnm

ent;

plan

s to

intr

oduc

e m

ore

coordinatedfinancing

of m

ultid

isci

plin

ary

team

ac

tiviti

es

Pat

ient

s: in

cent

ive

to re

mai

n in

the

com

mun

ity r

athe

r th

an b

ecom

ing

inst

itutio

naliz

ed

Notspecified

Prin

cipa

lly im

plem

ente

d in

all

60

mun

icip

aliti

es o

f Lith

uani

aP

reci

se d

ata

on p

opul

atio

n co

vera

ge a

re la

ckin

g; a

cces

s to

cas

e m

anag

emen

t var

ies

by c

ondi

tion

and

likel

y ac

ross

m

unic

ipal

ities

Clin

ical

gui

delin

esFu

nded

from

usu

al

sour

ces

(SH

I)G

Ps:

add

ition

al

paym

ent,

for

exam

ple,

for

confirm

ationofearly

diag

nose

d ca

ses

(for

exam

ple,

can

cer)

and

cert

ain

prio

ritiz

ed

serv

ices

Notspecified

In p

rinci

ple,

clin

ical

gui

delin

es s

houl

d be

im

plem

ente

d ac

ross

hea

lth s

ervi

ces

in

Lith

uani

a; p

reci

se d

ata

are

not a

vaila

ble

In p

rinci

ple,

all

diag

nose

d pa

tient

s sh

ould

be

cove

red

by

care

pla

ns b

ased

on

clin

ical

gu

idel

ines

Net

herla

nds

Mat

ador

DM

P/

Maa

stric

ht–

Heu

vella

nd

Usu

al s

ourc

es fo

r pr

ovid

ers

incl

udin

g G

Ps,

sp

ecia

lists

, die

titia

ns a

nd

othe

r he

alth

pro

fess

iona

ls;

spec

ialis

t dia

bete

s nu

rses

fu

nded

und

er p

revi

ous

Gen

eral

Exc

eptio

nal

Med

ical

Exp

ense

s A

ct

Notspecified

Notspecified

In 2

006,

a to

tal o

f 63

of 9

0 G

Ps

(70%

) in

the

Maa

stric

ht re

gion

par

ticip

ated

in th

e M

atad

or p

rogr

amm

e

In 2

006,

abo

ut 3

000

patie

nts

with

dia

bete

s in

the

Maa

stric

ht

regi

on w

ere

cove

red

by th

e M

atad

or p

rogr

amm

e

Prim

ary

care

gro

up

ZiO

(Maa

stric

ht–

Heu

vella

nd)

Fund

ed fr

om u

sual

so

urce

s (m

anda

tory

in

sura

nce)

, prin

cipa

l co

ntra

ctor

is th

e he

alth

in

sure

r C

oöpe

ratie

VG

Z on

the

basi

s of

a b

undl

ed

paym

ent c

ontr

act

Phy

sici

ans:

bun

dled

paym

entfordefined

pack

age

of c

are.

In

sure

r: to

neg

otia

te

low

pric

e fo

r ca

re

chai

n

Pre

senc

e of

an

acad

emic

hos

pita

l; profilingofZiOas

dire

ctor

of r

egio

nal

prim

ary

care

sec

tor

All

regi

onal

GP

s ar

e m

embe

rs o

f ZiO

H

euve

lland

and

as

such

par

ticip

ate

in th

e di

abet

es c

are

prog

ram

me

(just

und

er 9

0 G

Ps

by th

e en

d of

200

9); t

here

wer

e 97

ca

re g

roup

s in

Mar

ch 2

010

with

bun

dled

pa

ymen

t con

trac

t with

a h

ealth

insu

rer,

mos

tly fo

r di

abet

es c

are

By

the

end

of 2

009,

the

prog

ram

me

cove

red

som

e 76

00 p

atie

nts

with

type

2

diab

etes

in th

e M

aast

richt

–H

euve

lland

regi

on

Table

3.4

con

td


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Net

herla

nds

cont

dS

trok

e se

rvic

e D

elft

Fund

ed fr

om u

sual

so

urce

s: b

asic

hea

lth

insu

ranc

e (G

P a

nd

hosp

ital s

ervi

ces)

; AW

BZ

(for

exam

ple,

reha

bilit

atio

n ce

ntre

; nur

sing

hom

e) a

nd

WM

O (h

ome

care

); sh

ared

ca

re n

urse

is fu

nded

by

all

thre

e sc

hem

es

Notspecified

Notspecified

Follo

win

g th

e ex

perie

nces

of p

ilots

, the

go

vern

men

t act

ivel

y pr

omot

ed fu

rthe

r im

plem

enta

tion

thro

ugh

brea

kthr

ough

pr

ojec

ts a

nd b

ench

mar

king

of s

trok

e se

rvic

es; a

s re

sult,

by

2003

, eac

h re

gion

ha

d de

velo

ped

at le

ast o

ne s

trok

e se

rvic

e (a

tota

l of 6

9 in

200

3)

Pre

cise

num

ber

of p

atie

nts

rece

ivin

g ca

re w

ithin

str

oke

serv

ices

not

kno

wn;

how

ever

, ac

cord

ing

to th

e D

utch

H

eart

Fou

ndat

ion,

the

69

stro

ke s

ervi

ces

pres

ent i

n th

e N

ethe

rland

s si

nce

2003

are

di

strib

uted

to a

leve

l tha

t sho

uld

sufficientlycoverallstroke

patie

nts

(aro

und

191

000

in

2007

)

Nat

iona

l car

e st

anda

rd fo

r va

scul

ar r

isk

man

agem

ent

Fund

ed fr

om u

sual

so

urce

s (m

anda

tory

in

sura

nce)

on

the

basi

s of

a b

undl

ed p

aym

ent

cont

ract

Phy

sici

ans:

bun

dled

paym

entfordefined

pack

age

of c

are.

In

sure

r: to

neg

otia

te

low

pric

e fo

r ca

re

chai

n

Notspecified

Com

pare

d w

ith d

iabe

tes,

ther

e ar

e re

lativ

ely

few

car

e gr

oups

for

the

prov

isio

n of

vas

cula

r ris

k m

anag

emen

t; of

55

care

gr

oups

sur

veye

d in

ear

ly 2

010,

two

had

a bu

ndle

d pa

ymen

t con

trac

t in

plac

e fo

r va

scul

ar r

isk

man

agem

ent,

whe

reas

17

wer

e pr

epar

ing

to c

ontr

act

Pre

cise

num

ber

of p

atie

nts

rece

ivin

g ca

re w

ithin

vas

cula

r ris

k m

anag

emen

t not

kno

wn;

lim

ited

to th

ose

rece

ivin

g se

rvic

es th

roug

h th

e th

ree

esta

blis

hed

stan

dard

s

Sw

itzer

land

Dia

Bai

d di

abet

es

care

net

wor

kFu

nded

by

the

Can

ton

of V

aud

(app

roxi

mat

ely

50%

) and

from

car

e ac

tiviti

es c

harg

ed to

the

patie

nts

and

reim

burs

ed

by th

eir

heal

th in

sure

rs

(app

roxi

mat

ely

50%

)

No

Notspecified

Join

tly r

un b

y th

e A

ssoc

iatio

n de

s ré

seau

x desoinsdelaCôte(oneofthefivecare

netw

orks

ope

ratin

g in

the

Can

ton

of V

aud)

an

d tw

o re

gion

al h

ospi

tals

Dia

Bai

d w

as to

cov

er 3

0% o

f th

e es

timat

ed p

opul

atio

n w

ith

diab

etes

in th

e N

yon–

Mor

ges

regi

on (a

ppro

xim

atel

y 60

00).

By

2009

, 720

pat

ient

s (1

2%) h

ad

been

reac

hed

(app

roxi

mat

ely

100–

150

new

pat

ient

s pe

r ye

ar)


Nam

eFu

ndin

gU

se o

f fi

nanc

ial

ince

ntiv

esO

ther

ince

ntiv

esD

istr

ibut

ion

Up

take

Sw

itzer

land

con

td

Bre

ast c

ance

r cl

inic

al p

athw

ay,

Laus

anne

U

nive

rsity

Hos

pita

l an

d La

usan

ne

Uni

vers

ity

Fina

nced

by

Laus

anne

U

nive

rsity

Hos

pita

lN

oP

eer

pres

sure

; co

mpe

titio

n fro

m

othe

r (h

ospi

tal)

prov

ider

s

Cur

rent

ly o

ffere

d by

Lau

sann

e U

nive

rsity

H

ospi

tal o

nly

but t

here

are

pla

ns fo

r it

to b

e ex

tend

ed to

oth

er re

gion

al h

ospi

tals

in th

e C

anto

n of

Vau

d

Pro

gram

me

curr

ently

cov

ers

appr

oxim

atel

y 35

% o

f new

br

east

can

cer

patie

nts

in th

e C

anto

n of

Vau

d; a

im is

to tr

eat

40%

of n

ew b

reas

t can

cer

patie

nts,

with

a m

inim

um o

f 150

pa

tient

s to

be

incl

uded

eac

h ye

ar

Del

ta p

hysi

cian

ne

twor

k, G

enev

aFi

nanc

ed w

ithin

the

Del

ta n

etw

ork

insu

ranc

e sc

hem

e pr

inci

pally

fo

llow

ing

usua

l fee

-for

-se

rvic

e re

imbu

rsem

ent

but w

ithin

a c

apita

ted

sche

me

with

rein

sura

nce

for

expe

nsiv

e ca

ses

Phy

sici

ans

rece

ive

a lu

mp

sum

of C

HF

200

each

tim

e th

ey

part

icip

ate

in a

qu

ality

circ

le

Pro

fess

iona

l co

mm

itmen

t to

impr

ovin

g th

e qu

ality

of c

are

In 2

013,

the

Del

ta n

etw

ork

com

pris

ed 2

60

phys

icia

ns (1

0–20

% g

ener

alis

ts, i

nter

nist

s,

GP

s); i

n th

e C

anto

n of

Vau

d, th

e ne

twor

k co

mpr

ised

140

phy

sici

ans

Acc

essi

ble

to a

ny re

side

nt

optin

g fo

r th

e D

elta

net

wor

k in

sura

nce

sche

me;

in 2

013,

D

elta

cov

ered

abo

ut 1

00 0

00

insu

red

mem

bers

acr

oss

the

cant

ons

of G

enev

a an

d Va

ud

Sour

ces:

Austr

ia: S

önni

chse

n, F

lam

m &

Nol

te (2

015)

; Den

mar

k: F

rølic

h, Ja

cobs

en &

Kna

i. (2

015)

; Eng

land

: Nol

te e

t al.

(201

5); E

stoni

a: L

ai &

Kna

i (20

15);

Fran

ce: C

hevr

eul e

t al.

(201

5); G

erm

any:

Erle

r, Fu

llert

on &

Nol

te (2

015)

; Hun

gary

: Gaa

l et a

l. (2

015)

; Ita

ly: R

icci

ardi

et a

l. (2

015)

; Lith

uani

a: L

ai e

t al.

(201

5); L

atvi

a: L

ai, K

nai &

Tau

be (2

015)

; the

Net

herla

nds:

Eliss

en e

t al.

(201

5); S

witz

erla

nd: P

eytre

man

n-Br

idev

aux

et a

l. (2

015)

Not

es: D

MP:

dise

ase

man

agem

ent p

rogr

amm

e; S

HI:

statu

tory

hea

lth in

sura

nce;

GP:

gen

eral

pra

ctiti

oner

; CO

PD: c

oron

ary

obstr

uctiv

e pu

lmon

ary

dise

ase;

NH

S: N

atio

nal H

ealth

Ser

vice

; CV

D: c

ardi

ovas

cula

r di

seas

e; F

IQC

S: F

onds

d’in

terv

entio

n po

ur la

qua

lité

et la

coo

rdin

atio

n de

s soi

ns; C

NAM

: Cai

sse

Nat

iona

le d

’Ass

uran

ce M

alad

ie; P

PS: p

arco

urs p

erso

nnal

isé d

es p

atie

nts (

pers

onal

ized

care

pro

gram

me)

; RC

P:

réun

ion

de c

once

rtat

ion

plur

idisc

iplin

aire

(mul

tidisc

iplin

ary

team

mee

ting)

; MIG

AC: M

issio

ns d

’inté

rêt g

énér

al e

t à l’

aide

à la

con

trac

tual

isatio

n; E

EP: é

valu

atio

n de

s pra

tique

s pro

fess

ionn

elle

s; C

HD

: cor

onar

y he

art d

iseas

e; V

ERAH

: Ver

sorg

ungs

assis

tent

in in

der

Hau

sarz

tpra

xis (

care

ass

istan

ts in

fam

ily p

ract

ice)

; CM

P: c

are

man

agem

ent p

rogr

amm

e; S

SN: S

ervi

zio S

anita

rio N

azio

nale

(Nat

iona

l Hea

lth S

ervi

ce);

P4P:

pay

-fo

r-pe

rform

ance

; ASL

: Azie

nda

Sani

taria

Loc

ale

(Loc

al H

ealth

Aut

horit

y); P

HC

: prim

ary

heal

th c

are;

ZIO

: Zor

g In

Ont

wik

kelin

g (C

are

In D

evel

opm

ent);

AW

BZ: A

lgem

ene W

et B

ijzon

dere

Zie

ktek

oste

n; W

MO

: (S

ocia

l Sup

port

Act

); C

HF:

Sw

iss fr

anc.

Table

3.4

con

td


A number of approaches have been implemented at national level; these include: the care management programme and the Quality and Outcomes Framework in England; quality management in primary health care and management at the primary/secondary care interface in Estonia; disease management programmes in Germany; treatment (and financing) protocols in Hungary; and the improving intersectoral collaboration programme in Lithuania. Several approaches have been implemented at the regional level but are being (gradually) rolled out towards countrywide coverage. These have frequently, although not always, evolved from pilot or experimental projects. Examples include: the diabetes disease management programmes in Austria; the Sophia diabetes and asthma care programme and cancer networks in France; the asthma disease management programme and (possibly) the diabetes care programme in Hungary; the IGEA diabetes disease management programme in Italy; and care groups and standards as well as stroke services in the Netherlands. In Denmark, the regional DMPs and integrated clinical pathways are expected to cover the entire resident population in due course. Some approaches are fairly localized but are being considered for implementation elsewhere, such as the previously described COPA in Paris.

3.5 Components of chronic disease management

As noted in the Introduction, data collection on approaches to chronic disease management in Europe has sought to examine the extent to which these make use of the four components considered key to providing high-quality care for those with chronic health problems as identified by the chronic care model. These components are:

• self-management support

• delivery system design

• decision support

• clinical information systems.

For each of the approaches reviewed, Table 3.5 provides an overview of the nature and scope of these four interacting components. We find that the large majority provides some form of patient self-management support, although the level of support offered varies considerably, for example, involving the provision of information material, such as through brochures (for example, Integrated stroke care Upper Austria; Delta physician network, Switzerland), routine assessment of clinical indicators (for example, clinical guidelines in Lithuania) or access to coaching and face-to-face or telephone follow-up (for example, the Raffaello project, Italy), lifestyle intervention training (for example, the


Matador diabetes disease management programme, the Netherlands) and counselling techniques (for example, National care standard for vascular risk management, the Netherlands). Most approaches involve patients in the development of a care or treatment plan and goal setting, and provide regular assessment of patient needs and problems. The extent to which these support mechanisms are implemented in practice is, however, often unclear.

In the majority of cases, self-management support is provided by health professionals including physicians (for example, diabetes disease management programmes in Austria and Germany; chronic disease management at the primary/secondary care interface in Estonia), or, more frequently, trained nurses (for example, selected integrate care pilots in England; quality management in primary care in Estonia; the Sophia diabetes and asthma care programme and provider networks in France; Care Coordination Pilot, asthma disease and diabetes care management programmes in Hungary; IGEA, Leonardo and Raffaello projects in Italy; care groups and stroke services in the Netherlands; the breast cancer clinical pathway in Lausanne, Switzerland). Self-management support provided by others including lay groups appears uncommon; examples include selected projects implemented within the Partnership for Older People Project set-up in England.

Most approaches reviewed here involve some form of delivery system design, but as with self-management support the nature and scope of related strategies varies. Common elements include a clear definition of roles, the development of (individualized) care or treatment pathways and patient follow-up. Several approaches use case-finding or risk stratification (for example, care coordination/interface management Styria, Austria; Partnership for Older People Project and integrated care pilots, England; France; selected integrated care contracts, Germany; Care Coordination Pilot, Hungary; Raffaello project, Italy; care groups, the Netherlands). These approaches also tend to involve case management, or indeed constitute dedicated case management approaches, such as within the Partnership for Older People Project and integrated care pilots in England; the COPA Coordinates of professional care for the Elderly in France; and the improving intersectoral collaboration approach in Lithuania, with case management elements also incorporated within selected GP contracts in Germany; the Care Coordination Pilot in Hungary; the “From On-Demand to Proactive Primary Care” programme in Tuscany, Italy; and the Matador diabetes disease management programme in the Netherlands.

These strategies are commonly supported by decision support tools, such as guidelines and protocols, developed at organizational, regional, national or international level with some strategies also incorporating training in translating national or regional guidelines to the local level, as, for example,


Table

3.5

C

ompo

nent

s of

chr

onic

dis

ease

man

agem

ent u

sed

in 1

2 E

urop

ean

coun

trie

s

Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Aus

tria

‘Therapie’

aktiv

dis

ease

m

anag

emen

t pr

ogra

mm

e

Edu

catio

n th

roug

h gr

oup

inst

ruct

ion;

invo

lvem

ent i

n go

al

sett

ing

and

timel

ines

, with

agr

eed

targ

ets

sign

ed jo

intly

; reg

ular

follo

w-

up

Pat

ient

man

agem

ent t

hrou

gh

coor

dina

ting

phys

icia

n w

ith

cond

ition

s fo

r re

ferr

al b

etw

een

leve

ls o

f car

e; re

gula

r pa

tient

fo

llow

-up

(in p

erso

n)

Car

e pa

thw

ays

deve

lope

d by

th

e A

ustr

ian

Soc

iety

of D

iabe

tes

(ÖD

G);

man

dato

ry p

rovi

der

trai

ning

pr

ogra

mm

es fo

r D

MP

phy

sici

ans;

an

nual

adv

ance

d tr

aini

ng s

essi

ons

and

qual

ity c

ircle

s

Sta

ndar

dize

d do

cum

enta

tion

of c

linic

al

and

diag

nost

ic m

easu

res

and

trea

tmen

t; na

tionw

ide

mon

itorin

g is

pla

nned

, but

re

gula

r fe

edba

ck re

port

s to

par

ticip

atin

g ph

ysic

ians

hav

e ye

t to

be e

stab

lishe

d

Inte

grat

ed s

trok

e ca

re U

pper

A

ustr

ia

Info

rmat

ion

(str

oke

awar

enes

s ca

mpa

igns

, bro

chur

es d

istr

ibut

ed

in G

P p

ract

ices

and

hos

pita

ls,

dedi

cate

d w

ebsi

te, t

arge

ted

lect

ures

)

Dev

elop

men

t of i

nteg

rate

d ca

re

path

way

s; re

gula

r (p

eer

grou

p)

meetings;d

efinedrolesfor

part

icip

atin

g pr

ovid

ers

Pra

ctic

e gu

idel

ines

(for

exa

mpl

e,

stro

ke c

heck

list f

or G

Ps)

; de

velo

pmen

t of i

nteg

rate

d ca

re

path

way

s ba

sed

on e

vide

nce-

base

d gu

idel

ines

Com

mon

dat

a w

areh

ouse

that

com

pile

s in

form

atio

n on

str

oke

patie

nts

colle

cted

by

par

ticip

atin

g or

gani

zatio

ns; p

rovi

der

feed

back

to m

onito

r an

d im

prov

e pr

oces

ses

and

outc

omes

Car

e co

ordi

natio

n/in

terfa

ce

man

agem

ent

Sty

ria

Invo

lvem

ent o

f pat

ient

s an

d th

eir

care

give

rs in

pla

nnin

g of

dis

char

ge

and

subs

eque

nt c

are

arra

ngem

ents

in

clud

ing

info

rmat

ion

and

prac

tical

as

sist

ance

, suc

h as

arr

ange

men

t of

devi

ces

and

serv

ices

Car

e co

ordi

nato

r ac

ts a

s ke

y co

ntac

t for

the

patie

nt, h

ospi

tal

andthepatient’sGP;regular

mee

tings

of t

he c

oord

inat

or w

ith

prov

ider

s ou

tsid

e ho

spita

l; ca

se-

finding

Che

cklis

t to

iden

tify

patie

nts

requ

iring

sup

port

by

the

care

m

anag

er; u

se o

f the

BR

AS

S in

dex

inGrazforcase-finding

Notspecified

Am

bula

tory

afte

r-ca

re o

f str

oke

patie

nts,

Sal

zbur

g

Acc

ess

to te

am o

f occ

upat

iona

l th

erap

ists

, spe

ech

ther

apis

ts a

nd

phys

ioth

erap

ists

in o

ne-t

o-on

e an

d gr

oup

sett

ings

; soc

ial a

ctiv

ities

; in

form

atio

n th

roug

h ev

ents

Team

of t

hera

pist

s le

d by

sen

ior

ther

apis

t and

phy

sici

an in

eac

h di

stric

t act

ing

as p

rogr

amm

e le

ad; r

egul

ar te

am m

eetin

gs a

nd

mee

tings

of p

roje

ct le

ader

s

Con

tinui

ng e

duca

tion

and

trai

ning

of

ther

apis

ts; a

cces

s fo

r th

erap

ists

to

mon

thly

gro

up s

uper

visi

on

mee

tings

Notspecified

Kar

diom

obil

– H

ome

care

for

patie

nts

with

ch

roni

c he

art

failu

re

Edu

catio

n ab

out t

he d

isea

se,

inst

ruct

ion

in s

elf-

mon

itorin

g an

d in

han

dlin

g em

erge

ncy

situ

atio

ns

by tr

aine

d nu

rse;

follo

w-u

p as

sess

men

t of p

atie

nt s

elf-

man

agem

ent c

ompe

tenc

es a

nd

need

s

Sup

port

of p

atie

nts

alon

g definedprotocolofthree

hom

e vi

sits

by

trai

ned

nurs

e;

nurs

e al

so a

cts

as k

ey p

oint

of

cont

act f

or p

atie

nts

and

as c

are

coor

dina

tor

in c

olla

bora

tion

with

G

P a

nd s

peci

alis

t out

patie

nt

clin

ic

Con

tinui

ng e

duca

tion

for

Kar

diom

obil

nurs

es o

n as

pect

s of

med

icat

ion,

qua

lity

assu

ranc

e,

com

mun

icat

ion

with

clin

icia

ns,

Iinfo

rmat

ion

tech

nolg

y

Not

inte

gral

par

t of t

he p

rogr

amm

e; p

lans

to

impl

emen

t an

elec

tron

ic in

form

atio

n sy

stem

that

allo

ws

for

the

shar

ing

of

patie

nt d

ata

with

in th

e pr

ogra

mm

e


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Den

mar

k

SIK

S p

roje

ct –

inte

grat

ed e

ffort

fo

r pe

ople

livi

ng

with

chr

onic

di

seas

e

Edu

catio

n an

d re

gula

r do

cum

enta

tion

of s

elf-

man

agem

ent

need

s an

d ac

tiviti

es; i

nvol

vem

ent i

n de

velo

ping

indi

vidu

aliz

ed tr

eatm

ent

plan

s an

d go

al s

ettin

g; a

cces

s to

phy

sica

l exe

rcis

e in

terv

entio

n;

info

rmat

ion

Cleardefinitionofro

lesand

task

s of

par

ticip

atin

g he

alth

pr

ofes

sion

als;

mul

tidis

cipl

inar

y te

am s

uppo

rts

the

deliv

ery

of re

habi

litat

ion;

regu

lar

patie

nt fo

llow

-up;

regu

lar

inte

rorg

aniz

atio

nal m

eetin

gs

Evi

denc

e-ba

sed

clin

ical

gui

delin

es

deve

lope

d by

SIK

S w

orki

ng

grou

ps; r

egul

ar p

rovi

der

educ

atio

n an

d tr

aini

ng

Mon

itorin

g of

pra

ctic

e te

am p

erfo

rman

ce;

syst

emat

ic c

olle

ctio

n of

clin

ical

and

ot

her

data

; use

of m

unic

ipal

IT p

latfo

rm

Sun

dhed

spor

tal;

prov

ider

s m

ay o

pera

te

thei

r ow

n da

taba

se

Reg

iona

l dis

ease

m

amag

emen

t pr

ogra

mm

es

(gen

eric

mod

el

as p

ropo

sed

in

2008

by

the

then

N

atio

nal B

oard

of

Hea

lth)

Structured(disease-specificand

gene

ral)

educ

atio

n; in

form

atio

n;

invo

lvem

ent i

n de

velo

ping

car

e tr

eatm

ent p

lan

and

goal

set

ting

incl

udin

g ag

reei

ng ti

mel

ine

and

met

hods

for

eval

uatio

n of

goa

ls;

regu

lar

asse

ssm

ent a

nd fo

llow

-up

of p

robl

ems

and

need

s

Clearlydefinedroles

of p

artic

ipat

ing

heal

th

prof

essi

onal

s; d

evel

opm

ent o

f in

divi

dual

ized

inte

grat

ed c

are

plan

s; G

P is

prin

cipa

l car

e co

ordi

nato

r w

ith s

uppo

rt b

y sp

ecia

list a

nd b

y ca

se m

anag

er

(usu

ally

spe

cial

ist n

urse

) for

co

mpl

ex p

atie

nts;

regu

lar

follo

w-

up

Clin

ical

gui

delin

es d

evel

oped

by

a w

orki

ng g

roup

and

bas

ed o

n na

tiona

l and

inte

rnat

iona

l clin

ical

gu

idel

ines

; pro

vide

r tr

aini

ng in

re

leva

nt d

isci

plin

es o

f chr

onic

di

seas

e, in

clud

ing

lifes

tyle

in

terv

entio

ns, s

elf-

man

agem

ent

supp

ort a

nd in

edu

catio

n co

mpe

tenc

ies

and

mot

ivat

ion

tech

niqu

es

Nat

iona

l adm

inis

trat

ive

regi

ster

s an

d cl

inic

al q

ualit

y da

taba

ses

allo

w fo

r da

ta

shar

ing

and

com

mun

icat

ion,

as

wel

l as

con

sist

ent d

ata

colle

ctio

n; q

ualit

y m

onito

ring

acco

rdin

g to

the

Dan

ish

Qua

lity

Mod

el (D

DK

M) a

nd th

e N

atio

nal

Indi

cato

r S

yste

m

Inte

grat

ed c

linic

al

path

way

sNotspecified

Cleardefinitionofresponsibilities

(dia

gnos

is, t

reat

men

t, re

habi

litat

ion)

; dev

elop

men

t of

indi

vidu

aliz

ed c

are

plan

s;

desi

gnat

ed c

are

coor

dina

tor;

re

gula

r fo

llow

-up

with

inte

rval

s de

pend

ing

on c

ondi

tion

Nat

iona

l clin

ical

gui

delin

esFr

om 2

012,

the

Sta

te S

erum

Inst

itute

(S

SI)

coor

dina

tes

the

Nat

iona

l Pat

ient

R

egis

try

and

the

Can

cer

Reg

iste

r;

establishedspecificcodesforthe

mon

itorin

g of

the

inte

grat

ed c

linic

al

path

way

s, w

ith re

port

ing

mad

e m

anda

tory

for

Dan

ish

hosp

itals

from

O

ctob

er 2

012.

Sim

ilar

code

s w

ere

also

est

ablis

hed

for

inte

grat

ed c

linic

al

path

way

s fo

r he

art d

isea

se; r

epor

ting

of

thes

e be

cam

e m

anda

tory

in J

uly

2013

Table

3.5

co

ntd


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Eng

land

Com

mun

ity

mat

ron

Edu

catio

n pr

ovid

ed b

y sp

ecia

list

nurs

e; in

volv

emen

t in

deve

lopm

ent

of c

are

plan

and

goa

ls; r

egul

ar

asse

ssm

ent a

nd d

ocum

enta

tion

of

need

s an

d ac

tiviti

es

Cleardefinitionofro

leswith

spec

ialis

t nur

se a

s ca

se

man

ager

, coo

rdin

atin

g w

ith

GP,

com

mun

ity a

nd s

ocia

l ca

re s

ervi

ces;

med

icin

es

managem

ent;case-findingusing

stan

dard

ized

ris

k as

sess

men

t

Trai

ning

of n

urse

s w

ithin

nat

iona

l co

mpe

tenc

y fra

mew

orks

and

gu

idan

ce

Mayincludeuseofriskstratification

tool

s to

iden

tify

patie

nts

at r

isk

of

reho

spita

lizat

ion;

ava

ilabi

lity

of IT

sup

port

/in

form

atio

n sh

arin

g va

riabl

e ac

ross

co

mm

issi

ners

Qua

lity

and

outc

omes

fra

mew

ork

n/a

Varie

s at

pra

ctic

e le

vel;

may

in

clud

e re

gula

r st

aff m

eetin

gs,

patie

nt fo

llow

-up

(usu

ally

by

phon

e or

pos

t), a

nd m

edic

ines

m

anag

emen

t

Use

of c

linic

al g

uide

lines

and

tr

aini

ng o

f pra

ctic

e nu

rses

on

the

basi

s of

indi

vidu

al le

arni

ng p

lans

Aut

omat

ed m

echa

nism

for

the

colle

ctio

n of

dat

a fo

r cl

inic

al q

ualit

y in

dica

tors

from

G

P e

lect

roni

c m

edic

al re

cord

s, in

clud

ing

dise

ase

regi

stra

tion

and

perfo

rman

ce

mon

itorin

g, th

roug

h na

tiona

l IT

syst

em;

data

ext

ract

s ar

e ac

cess

ible

to th

e H

ealth

an

d S

ocia

l Car

e In

form

atio

n C

entr

e to

su

ppor

t pub

licat

ion

Par

tner

ship

for

olde

r pe

ople

pr

ojec

t (P

OP

P)

Varie

d: in

volv

emen

t of o

lder

peo

ple

in p

roje

ct d

evel

opm

ent,

oper

atio

n an

d ev

alua

tion;

pee

r su

ppor

t, in

clud

ing

EE

P; s

taff

and

volu

ntee

rs

actin

g as

“na

viga

tors

” to

hel

ping

ol

der

peop

le th

roug

h th

e sy

stem

; fo

llow

-up;

exp

ert c

arer

pro

gram

me;

Varie

d: c

omm

unity

-bas

ed m

ulti-

agen

cy te

ams;

dev

elop

men

t of

inte

grat

ed c

are

path

way

s;

mul

tidis

cipl

inar

y he

alth

and

so

cial

car

e te

ams;

des

igna

ted

role

s, in

clud

ing

com

mun

ity

mat

rons

and

cas

e w

orke

rs

(soc

ial/“

hybr

id”

wor

kers

); ca

se-

finding;regularfollow-up

Varie

d: h

ealth

or

soci

al c

are

staf

f tr

aini

ng; v

olun

teer

trai

ning

; ski

ll sh

arin

g an

d tr

aini

ng; a

cces

s to

sp

ecia

list e

xper

tise

Varie

d: in

tegr

ated

IT s

yste

ms

conn

ectin

g pr

imar

y an

d se

cond

ary

care

, or

prim

ary

and

soci

al/c

omm

unity

car

e; u

se o

f telehealthtechnologyandcase-finding

softw

are;

use

of w

irele

ss te

chno

logy

for

mob

ile u

nits

IInte

grat

ed c

are

pilo

tsVa

ried:

pat

ient

edu

catio

n an

d pr

ovis

ion

of s

elf-

man

agem

ent t

ools

by

sen

ior

nurs

es; t

rain

ing

in s

elf-

man

agem

ent o

f med

icin

es

Varie

d: d

evel

opm

ent o

f car

e pa

thw

ays;

man

aged

dis

char

ge;

case

man

agem

ent,

led

by

seni

or/s

peci

alis

t nur

ses;

use

of

inte

grat

ed c

omm

unity

team

s pr

ovid

ing

a si

ngle

poi

nt o

f ac

cess

for

patie

nts

Varie

d: h

ealth

or

soci

al c

are

prof

essi

onal

trai

ning

, par

ticul

arly

re

gard

ing

gene

ric s

kills

that

en

able

mor

e ef

fect

ive

wor

k on

m

ultid

isci

plin

ary

team

s or

in a

ra

pid-

resp

onse

cap

acity

; acc

ess

to s

peci

alis

t exp

ertis

e

Varied:case-findingsoftware;afewsites

aim

ed to

est

ablis

h a

sing

le in

tegr

ated

IT

sys

tem

for

prim

ary

and

com

mun

ity

care

, whi

le o

ther

s m

ake

use

of te

leca

re

serv

ices

and

rem

ote

heal

th m

onito

ring


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Est

onia

Qua

lity

man

agem

ent i

n pr

imar

y he

alth

ca

re

Edu

catio

n pr

ovid

ed b

y G

P/f

amily

nu

rse;

invo

lvem

ent i

n de

velo

pmen

t of

car

e pl

an; r

egul

ar a

sses

smen

t an

d fo

llow

-up;

add

ition

al s

uppo

rt

by h

ome

care

nur

se o

r so

cial

w

orke

r w

here

nec

essa

ry

Case-finding;d

evelop

ment

of in

divi

dual

ized

car

e an

d tr

eatm

ent p

lans

; rou

tine

follo

w-

up

Evi

denc

e-ba

sed

diag

nosi

s,

trea

tmen

t and

dis

ease

m

anag

emen

t gui

delin

es; p

rovi

der

educ

atio

n as

par

t of c

ontin

uing

pr

ofes

sion

al d

evel

opm

ent i

n pr

imar

y an

d sp

ecia

list c

are;

qua

lity

man

agem

ent a

ctiv

ities

GP

pra

ctic

e in

form

atio

n sy

stem

ac

cord

ing

to m

anda

tory

gui

delin

es

incl

udin

g el

ectr

onic

med

ical

reco

rds,

bo

okin

g an

d re

min

der

syst

ems;

IT

syst

em li

nked

to c

ount

ryw

ide

patie

nt

and

trea

tmen

t sys

tem

of a

ll he

alth

car

e pr

ovid

ers

(ava

ilabl

e on

line

from

200

9)

Chr

onic

dis

ease

m

anag

emen

t at

the

prim

ary/

seco

ndar

y ca

re

inte

rface

Edu

catio

n (s

peci

alis

t); in

volv

emen

t in

dev

elop

men

t of c

are

plan

; re

gula

r as

sess

men

t and

follo

w-u

p;

men

torin

g/pe

er s

uppo

rt th

roug

h pa

tient

ass

ocia

tions

(for

exa

mpl

e,

multiplesclerosis,P

arkinson’s

dise

ase)

; sup

port

at h

ome

by n

urse

or

soc

ial w

orke

r w

here

nec

essa

ry

Case-finding;d

evelop

ment

of in

divi

dual

ized

car

e an

d tr

eatm

ent p

lans

; rou

tine

follo

w-

up

Evi

denc

e-ba

sed

diag

nosi

s,

trea

tmen

t and

dis

ease

m

anag

emen

t gui

delin

es; p

rovi

der

educ

atio

n as

par

t of c

ontin

uing

pr

ofes

sion

al d

evel

opm

ent i

n pr

imar

y an

d sp

ecia

list c

are

GP

pra

ctic

e in

form

atio

n sy

stem

ac

cord

ing

to m

anda

tory

gui

delin

es

incl

udin

g el

ectr

onic

med

ical

reco

rds,

bo

okin

g an

d re

min

der

syst

ems;

IT

syst

em li

nked

to c

ount

ryw

ide

patie

nt

and

trea

tmen

t sys

tem

of a

ll he

alth

car

e pr

ovid

ers

(ava

ilabl

e on

line

from

200

9)

Fran

ceP

rovi

der

netw

orks

Fo

r ex

ampl

e,

(dia

bete

s ne

twor

ks):

RE

VE

SD

IAB

Info

rmat

ion

and

educ

atio

n (fo

r ex

ampl

e, d

iet);

coa

chin

g by

nu

rses

; inv

olve

men

t in

deve

lopi

ng

trea

tmen

t pla

n to

war

ds a

form

al

agre

emen

t bet

wee

n pa

tient

and

ne

twor

k; re

gula

r as

sess

men

t and

fo

llow

-up

incl

udin

g pa

tient

logb

ook

com

plet

ed w

ith d

octo

r co

nsul

ted

Cleardefinitionofro

les

of m

ultid

isci

plin

ary

heal

th

care

team

; dev

elop

men

t of

indi

vidu

aliz

ed c

are

plan

by

core

te

am; d

iscu

ssio

n fo

rum

and

qu

ality

circ

les;

regu

lar

follo

w-u

p

Evi

denc

e-ba

sed

guid

elin

es a

nd

care

pro

toco

ls; p

rovi

der

trai

ning

w

ithin

con

tinuo

us m

edic

al

educ

atio

n

Sha

red

info

rmat

ion

syst

em in

volv

ing

a da

taba

se c

olle

ctin

g ro

utin

e cl

inic

al

indi

cato

rs a

nd u

sed

for

eval

uatio

n an

d qu

ality

con

trol

; pat

ient

-hel

d ca

re fo

lder

to

sup

port

mon

itorin

g; s

ome

syst

ems

oper

ate

rem

inde

r fu

nctio

ns; G

Ps

do n

ot

have

rout

ine

acce

ss to

cen

tral

ized

pat

ient

in

form

atio

n

Coo

rdin

atio

n of

pr

ofes

sion

al c

are

for

the

Eld

erly

(C

OPA

)

Invo

lvem

ent i

n de

velo

ping

tr

eatm

ent p

lan

and

goal

set

ting

Clearlydefinedroleswith

trai

ned

nurs

e as

cas

e m

anag

er;

deve

lopm

ent o

f ind

ivid

ualiz

ed

care

pla

n; o

ccas

iona

l m

ultid

isci

plin

ary

team

mee

tings

(G

P, g

eria

tric

ian,

car

egiv

ers)

; case-finding

Pro

vide

r tr

aini

ng in

ger

iatr

ic

asse

ssm

ent (

Inte

rRA

I) to

info

rm

careplanandcase-finding

Dat

abas

e fo

r ev

alua

tion

and

docu

men

tatio

n; to

be

inte

grat

ed in

the

clin

ical

rout

ine

in th

e fu

ture

Table

3.5

co

ntd


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Fran

ce c

ontd

Spe

cific

pro

gram

mes

Sop

hia

diab

etes

an

d as

thm

a ca

re

prog

ram

me

(by

SH

I)

Adv

ice

and

info

rmat

ion

on s

elf-

man

agem

ent o

f dis

ease

and

he

alth

beh

avio

ur; f

acilit

atin

g co

mm

unic

atio

n w

ith h

ealth

pr

ofes

sion

als;

acc

ess

to d

edic

ated

pr

ogra

mm

e w

ebsi

te

Cleardefinitionofro

les:regular

indi

vidu

aliz

ed (n

eed-

base

d)

phon

e in

terv

entio

n by

trai

ned

nurs

e w

ith G

P re

mai

ning

car

e coordinator;stratificationof

patie

nts

acco

rdin

g to

ris

k to

det

erm

ine

frequ

ency

of

inte

rven

tion

Evi

denc

e-ba

sed

guid

elin

esRiskstratificationsoftw

are

Hea

lth A

ctio

n by

Te

ams

of S

elf-

empl

oyed

Hea

lth

Pro

fess

iona

ls

(AS

ALE

E)

Edu

catio

n ab

out d

isea

se p

rovi

ded

by tr

aine

d nu

rse

Clearlydefinedrolesforstaff

with

nur

ses

resp

onsi

ble

for

scre

enin

g fo

r co

gniti

ve p

robl

ems

and

card

iova

scul

ar r

isk

fact

ors

in in

divi

dual

s ov

er 7

5 ye

ars

Notspecified

Rem

inde

r sy

stem

s on

pat

ient

not

es a

nd

mon

itorin

g sy

stem

s

Hos

pita

l di

scha

rge

prog

ram

for

hear

t fa

ilure

pat

ient

s (P

RA

DO

)

Wee

kly

hom

e vi

sit b

y nu

rse

durin

g tw

o m

onth

s to

del

iver

pat

ient

ed

ucat

ion;

sup

port

bro

chur

es fo

r pa

tient

s

Org

aniz

atio

n an

d co

ordi

natio

n of

follo

w-u

p co

nsul

tatio

ns b

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posi

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ing

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t the

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ess

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Rolesofstaffareclearlydefined

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tem

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cer

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nt re

cord

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er, i

mpl

emen

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ss re

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s


Nam

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cer

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n co

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tidis

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y te

am m

eetin

g (R

CP

)

As

impl

emen

ted

with

in d

ispo

sitif

d’annonce

Dev

elop

men

t of i

ndiv

idua

lized

ca

re p

lans

(PP

S);

staf

f rol

es a

re

clearlydefinedwithmédecin

refe

rent

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errin

g do

ctor

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epar

ing

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t tre

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ent p

lan

for

disc

ussi

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ith te

am; w

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ance

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Reg

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tions

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er

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tice

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l re

com

men

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ns is

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tem

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ve b

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cer

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nt re

cord

s (D

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er c

omm

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wev

er, i

mpl

emen

tatio

n ha

s va

ried

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ss re

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s

Reg

iona

l can

cer

netw

orks

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emen

ted

with

in d

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sitif

d’annonce

As

impl

emen

ted

with

in R

CP

; in

addi

tion:

regu

lar

(mon

thly,

six

-m

onth

ly) m

eetin

gs o

f pro

vide

rs

in th

e fo

rm o

f wor

ksho

ps fo

r ea

ch g

roup

of s

peci

altie

s of

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ce, f

or

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ple,

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n in

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e,

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es

As

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ted

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Sys

tem

s ha

ve b

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tatio

n ha

s va

ried

acro

ss re

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s

Loca

l can

cer

or

loca

l mul

tiple

pa

thol

ogy

netw

orks

As

impl

emen

ted

with

in d

ispo

sitif

d’annonce

Par

ticip

atio

n of

GP

s in

m

ultid

isci

plin

ary

cons

ulta

tion;

de

velo

pmen

t of m

onito

ring

plan

by

GP

cov

erin

g ep

isod

es

betw

een

hosp

italiz

atio

ns,

trea

tmen

t at h

ome

and

mon

itorin

g af

ter-

care

As

impl

emen

ted

with

in R

CP

with

an

ele

men

t of p

rovi

der

educ

atio

n at

loca

l lev

el (G

Ps,

hom

e ca

re

nurs

es) a

s m

eans

to im

plem

ent

regi

onal

gui

delin

es; a

cces

s to

sp

ecia

list e

xper

tise

in h

ospi

tal

Acc

ess

of G

Ps

to e

lect

roni

c pa

tient

re

cord

s of

par

ticip

atin

g pa

tient

s

Table

3.5

co

ntd


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Ger

man

y

Dis

ease

m

anag

emen

t pr

ogra

mm

es

Edu

catio

n pr

ogra

mm

e in

gro

up

sess

ions

; inv

olve

men

t in

agre

eing

tr

eatm

ent g

oals

; reg

ular

follo

w-u

p,

with

pat

ient

rem

inde

rs fo

r m

isse

d se

ssio

ns; s

ome

SH

I fun

ds a

lso

offe

r te

leph

one

serv

ices

to fu

rthe

r su

ppor

t the

ir m

embe

rs p

artic

ipat

ing

in D

MP

s

Coo

rdin

atio

n of

thre

e ca

re

levelsaccordingto

specified

cond

ition

s fo

r re

ferr

al b

etw

een

leve

ls o

f car

e; re

gula

r pa

tient

fo

llow

-up

Evi

denc

e-ba

sed

guid

elin

es a

s de

velo

ped

by th

e G

erm

an N

etw

ork

for

Evi

denc

e-ba

sed

Med

icin

e an

d InstituteforQualityandEfficiency

in H

ealth

Car

e; p

artic

ipat

ing

physicianshavetomeetd

efined

trai

ning

sta

ndar

ds a

nd m

ay h

ave

to a

tten

d fu

rthe

r tr

aini

ng; f

urth

er

trai

ning

or

qual

ity c

ircle

s on

a

regu

lar

basi

s

Sta

ndar

dize

d el

ectr

onic

doc

umen

tatio

n oftreatm

ent,patient’sconditionandtest

resu

lts, m

edic

atio

n re

gim

e an

d ag

reed

tr

eatm

ent g

oals

; cen

tral

dat

a an

alys

is

to p

rodu

ce q

ualit

y re

port

s. a

nd p

rovi

der

feed

back

on

perfo

rman

ce a

nd fo

r be

nchm

arki

ng

GP

con

trac

tsA

nnua

l che

ck-u

ps; a

dvic

e on

pre

vent

ive

mea

sure

s an

d in

form

atio

n; a

sses

smen

t of

card

iova

scul

ar r

isk

fact

ors

(arr

iba

softw

are)

sup

port

s sh

ared

dec

isio

n-m

akin

g on

trea

tmen

t opt

ions

GP

act

s as

gat

ekee

per

to s

peci

alis

t car

e; c

ase

managem

entledbyqualified

nurs

es/p

ract

ice

assi

stan

ts is

en

cour

aged

Trea

tmen

t gui

delin

es b

y as

soci

atio

n of

fam

ily p

hysi

cian

s;

requ

irem

ent t

o pa

rtic

ipat

e in

(c

ontin

uous

) pro

fess

iona

l tra

inin

g,

sele

cted

DM

Ps

and

in a

t lea

st fo

ur

qual

ity c

ircle

s pe

r ye

ar; t

rain

ing

in p

sych

osom

atic

med

icin

e an

d re

habi

litat

ion

care

(Opt

iona

l) us

e of

ele

ctro

nic

med

ical

re

cord

(pat

ient

pas

spor

t); e

xter

nally

cr

eate

d fe

edba

ck re

port

s fo

r ph

ysic

ians

; re

quire

men

t to

impl

emen

t a q

ualit

y m

anag

emen

t sys

tem

Inte

grat

ed c

are/

Hea

lthy

Kin

zigt

alR

egul

ar c

heck

-ups

and

ris

k as

sess

men

ts; i

nvol

vem

ent i

n th

e de

velo

pmen

t of i

ndiv

idua

l tr

eatm

ent/

prev

entio

n pl

ans

and

goal

set

ting;

repr

esen

tatio

n th

roug

h pa

tient

adv

isor

y bo

ard

and

a pa

tient

om

buds

man

Clearlydefinedroleswith

identifiedcarecoordinators;

inte

grat

ed p

rovi

der

netw

ork

and

desi

gnat

ed m

anag

emen

t or

gani

zatio

n re

spon

sibl

e fo

r pr

ovid

er c

oord

inat

ion;

cas

e-finding

Trea

tmen

t gui

delin

es fo

r ov

er 1

5 di

seas

es; p

rovi

ders

and

exp

erts

fro

m th

e pa

rtic

ipat

ing

SH

I fun

ds

colla

bora

te in

wor

king

gro

ups

to d

evel

op g

uide

lines

and

car

e pa

thw

ays

Qua

lity

man

agem

ent s

yste

m a

nd

elec

tron

ic p

atie

nt re

cord

s; re

gula

r an

alys

is o

f pat

ient

dat

a us

ing

pred

ictiv

e m

odel

ling

to id

entif

y hi

gh-c

ost r

isks

Com

mun

ity

nurs

es: c

are

assi

stan

t in

fam

ily

prac

tice

(Ver

AH

)

Acc

ess

to tr

aine

d ca

se m

anag

ers

Del

egat

ion

of ta

sks

to p

ract

ice

assi

stan

ts a

nd p

erfo

rmed

un

der

the

supe

rvis

ion

of th

e G

P; u

sual

ly fo

rms

part

of G

P

cont

ract

Par

t of G

P c

ontr

act a

s de

scrib

ed

abov

e un

der

GP

con

trac

tsP

art o

f GP

con

trac

t as

desc

ribed

abo

ve


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Hun

gary

Trea

tmen

t (andfinancing)

prot

ocol

s

Info

rmat

ion

mat

eria

l on

canc

er,

hype

rten

sion

and

oth

er C

VD

; sel

f-m

anag

emen

t sup

port

by

patie

nt

asso

ciat

ions

and

by

heal

th c

are

staf

f pre

disc

harg

e fo

r ho

spita

lized

pa

tient

s (c

ance

r, C

VD

)

Not

app

licab

leU

se o

f tre

atm

ent g

uide

lines

/pr

otoc

ols

deve

lope

d by

pr

ofes

sion

al a

ssoc

iatio

ns o

n th

e ba

sis

of b

est a

vaila

ble

evid

ence

w

ith v

aria

tion

in q

ualit

y of

gu

idel

ines

; pro

vide

r ed

ucat

ion

for

som

e co

nditi

ons,

org

aniz

ed a

t th

e na

tiona

l lev

el a

nd fr

eque

ntly

su

ppor

ted

by p

harm

aceu

tical

co

mpa

nies

Nat

iona

l dis

ease

regi

strie

s ar

e in

pla

ce fo

r ca

ncer

, ast

hma/

CO

PD

, car

diov

ascu

lar

dise

ase

Car

e co

ordi

natio

n pi

lot

Edu

catio

n by

spe

cial

ized

nur

ses;

in

volv

emen

t in

deve

lopi

ng

trea

tmen

t pla

n an

d go

al s

ettin

g;

acce

ss to

sel

f-m

anag

emen

t too

ls;

regu

lar

asse

ssm

ent o

f pro

blem

s/ac

com

plis

hmen

ts

Car

e co

ordi

natio

n or

gani

zatio

n re

spon

sibl

e fo

r ca

re d

eliv

ery

to a

n en

rolle

d po

pula

tion;

re

gula

r m

eetin

gs o

f pro

vide

rs;

med

icin

es m

anag

emen

t; case-findingandfollow-up;

case

man

agem

ent;

syst

emat

ic

scre

enin

g

Use

of l

ocal

car

e pa

thw

ays

and

of e

vide

nce-

base

d gu

idel

ines

de

velo

ped

by c

are

coor

dina

tion

orga

niza

tion

and

disc

usse

d w

ith

loca

l pro

vide

rs

NIH

FA d

atab

ase

on h

ealth

car

e us

e to

ana

lyse

pro

vide

r pe

rform

ance

and

feedback;createpatientprofilesto

id

entif

y ne

ed

Mul

tifun

ctio

nal

com

mun

ity

cent

res

Pat

ient

edu

catio

n m

ay b

e pr

ovid

edC

omm

unity

cen

tre

inte

grat

es

prim

ary,

spe

cial

ist c

are

and

soci

al c

are;

dev

elop

men

t and

us

e of

inte

grat

ed c

are

path

way

s

Not

app

licab

leIm

plem

enta

tion

of in

tegr

ated

info

rmat

ion

syst

em is

a re

quire

men

t

Ast

hma

dise

ase

man

agem

ent

prog

ram

me

Pat

ient

edu

catio

n on

ast

hma;

ac

cess

to s

elf-

mon

itorin

g to

ols;

in

volv

emen

t in

trea

tmen

t pla

n,

goal

set

ting,

dec

isio

n-m

akin

g;

regu

lar

asse

ssm

ent o

f pro

blem

s/ac

com

plis

hmen

ts

Asthm

anurseispatient’sfirst

poin

t of c

onta

ct, a

nd c

ase

man

ager

; reg

ular

sta

ff m

eetin

gs;

resp

onsi

bilit

y of

all

care

de

cisi

ons

rem

ain

with

trea

ting

phys

icia

n

Use

of t

reat

men

t pla

ns b

ased

on

evid

ence

-bas

ed g

uide

lines

and

tr

aini

ng o

f pro

vide

rs, i

n pa

rtic

ular

as

thm

a nu

rse

Use

of a

nat

iona

l reg

istr

y of

ast

hma

patie

nts

mai

ntai

ned

by N

atio

nal

Kor

ányi

Inst

itute

of T

uber

culo

sis

and

Pul

mon

olog

y; n

urse

s ke

ep d

etai

led

reco

rds

of e

ach

patie

nt

Table

3.5

co

ntd


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Hun

gary

con

tdD

iabe

tes

care

m

anag

emen

t pr

ogra

mm

e

Edu

catio

n pr

ovid

ed b

y a

diab

etes

nu

rse;

acc

ess

to s

elf-

mon

itorin

g de

vice

s (g

luco

met

er);

regu

lar

follo

w-u

p to

rout

inel

y as

sess

pr

oble

ms

and

acco

mpl

ishm

ents

, bo

th in

per

son

and

by te

leph

one

Cleardefinitionofro

lesofhealth

care

sta

ff; re

gula

r st

aff m

eetin

gs

to d

iscu

ss p

robl

emat

ic c

ases

; re

gula

r fo

llow

-up

of p

atie

nts;

us

e of

dis

char

ge s

ocia

l nur

ses

who

coo

rdin

ate

soci

al s

uppo

rt

(cas

h an

d in

kin

d)

Evi

denc

e-ba

sed

trea

tmen

t gu

idel

ines

dev

elop

ed a

nd re

gula

rly

upda

ted

by th

e H

unga

rian

Dia

bete

s A

ssoc

iatio

n an

d th

e tr

aini

ng o

f hea

lth c

are

staf

f, in

pa

rtic

ular

spe

cial

ist d

iabe

tes

nurs

es

Pla

nned

; str

ateg

ies

envi

sage

d in

clud

e re

min

der

syst

ems,

ele

ctro

nic

book

ing

syst

em a

nd p

rovi

der

feed

back

Italy

Inte

grat

ion,

m

anag

emen

t and

as

sist

ance

for

diab

etes

(IG

EA

)

Str

uctu

red

diab

etes

edu

catio

n by

trai

ned

staf

f (sp

ecia

lists

, nu

rses

, GP

s); i

nvol

vem

ent i

n de

velo

ping

car

e pl

an; a

cces

s to

se

lf-m

anag

emen

t too

ls; r

outin

e as

sess

men

ts o

f pro

blem

s an

d ac

com

plis

hmen

ts

Use

of i

nteg

rate

d ca

re

path

way

s; s

peci

alis

t nur

se

deve

lops

indi

vidu

aliz

ed

care

or

trea

tmen

t pla

ns;

team

com

posi

tion

varie

s in

ac

cord

ance

with

indi

vidu

al

patient’sneeds

Evi

denc

e-ba

sed

guid

elin

es fo

r th

e m

anag

emen

t of t

ype

2 di

abet

es

and

two-

stag

e pr

ovid

er tr

aini

ng:

trai

ning

-the

-tra

iner

s st

age

at

natio

nal a

nd re

gion

al le

vel a

nd

indi

vidu

al p

rovi

der

educ

atio

n w

ith fe

edba

ck fo

r pr

ogra

mm

e im

prov

emen

t

Reg

istr

ies

of p

atie

nts

with

dia

bete

s en

rolle

d in

the

prog

ram

me

alth

ough

fo

rmat

var

ies

by re

gion

; doc

umen

t “T

he in

form

atio

n sy

stem

” se

ts o

ut

the

prin

cipl

es fo

r th

e de

velo

pmen

t of

info

rmat

ion

syst

ems

“Fro

m O

n-D

eman

d to

P

roac

tive

Prim

ary

Car

e”

prog

ram

me,

Tu

scan

y

Edu

catio

n an

d co

unse

lling;

in

stru

ctio

n in

sel

f-m

onito

ring

activ

ities

; inv

olve

men

t in

deve

lopi

ng

and

cons

ent t

o ca

re p

lan;

regu

lar

asse

ssm

ents

of p

robl

ems

and

need

s; s

uppo

rt b

y so

cial

wor

kers

w

here

nee

ded

Clin

ical

pat

hway

s de

liver

ed

by G

P-le

d te

ams;

per

iodi

c m

eetin

gs w

ith c

omm

unity

he

alth

doc

tor

at th

e lo

cal

heal

th a

utho

rity

(AS

L); s

taff

rolesclearlydefinedincluding

flowcharts;staffnurseforcase

man

agem

ent a

nd c

ouns

ellin

g

Evi

denc

e-ba

sed

guid

elin

es to

in

form

clin

ical

pat

hway

s an

d co

mpr

ehen

sive

pro

gram

me

of

peer

edu

catio

n fo

r al

l pro

fess

iona

ls

invo

lved

and

sin

gle

grou

ps o

f professionalsonspecificissues;

acce

ss to

spe

cial

ist e

xper

tise;

nu

rse

trai

ning

Dat

abas

es o

n en

rolle

d pa

tient

s to

m

onito

r pe

rform

ance

of p

ract

ice

team

in

regu

lar

mee

tings

; inf

orm

atio

n sh

arin

g am

ong

team

mem

bers

thro

ugh

lead

GP

s el

ectr

onic

sys

tem

; ele

ctro

nic

book

ing

syst

em in

pla

ce

Leon

ardo

pilo

t pr

ojec

t, P

uglia

Edu

catio

n ba

sed

on th

e ei

ght

prioritiesapproachdefinedbyLorig

& H

olm

an; s

yste

mat

ic a

sses

smen

t of

pat

ient

nee

ds (i

n pe

rson

/by

tele

phon

e) a

nd fo

llow

-up

Car

e m

anag

er w

orks

with

GP

todeliverindividualpatient’s

care

pla

n; s

taff

role

s ar

e cl

early

defined;regularstaffmeetings;

flowchartsdescribeactivitiesset

out i

n th

e ca

re p

lan;

med

icin

es

man

agem

ent

Evi

denc

e-ba

sed

prin

cipl

es o

f ca

re m

anag

emen

t and

sco

ring

syst

ems

and

trai

ning

of s

taff

(car

e m

anag

ers

in c

ouns

ellin

g an

d co

mm

unic

atio

n te

chni

ques

; GP

s in

us

e of

the

prog

ram

me

softw

are)

; sp

ecia

list e

xper

tise

is a

vaila

ble

whe

re re

quire

d

Sof

twar

e, In

form

aCar

e™: r

emin

ders

for

prov

ider

s; d

ata

colle

ctio

n fo

r per

form

ance

as

sess

men

t; co

ntin

uous

mon

itorin

g of

pr

ogre

ss; i

nfor

mat

ion

shar

ing.

Ele

ctro

nic

book

ing

syst

em in

pla

ce


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Italy

Raf

fael

lo p

roje

ct,

Mar

che

and

Abr

uzzo

Par

ticip

atio

n in

dev

isin

g ca

re p

lan

and

deci

sion

-mak

ing;

acc

ess

to

coac

hing

and

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w-u

p ac

tiviti

es

bytelephone,doctor’soffice

orpatient’shom

e;accessto

info

rmat

ion

mat

eria

l on

dise

ase,

se

rvic

es a

vaila

bilit

y an

d lif

esty

le

Car

e m

anag

er w

orks

with

GP

todeliverindividualpatient’s

care

pla

n; s

taff

role

s ar

e cl

early

defined;useofcase-finding

thro

ugh

mea

sure

s of

prim

ary

prev

entio

n

Pro

vide

r ed

ucat

ion

(trai

ning

-the

-tr

aine

rs a

nd in

divi

dual

pro

vide

r tr

aini

ng fo

r G

Ps

and

care

m

anag

ers)

; acc

ess

to s

peci

alis

t ex

pert

ise

and

expe

rienc

e is

m

entio

ned,

but

spe

cial

ists

do

not

play

an

activ

e ro

le in

the

team

; pr

eim

plem

enta

tion

sim

ulat

ion

to

asse

ss im

pact

of p

ropo

sed

care

st

rate

gy o

n ex

istin

g or

gani

zatio

n

Sof

twar

e de

velo

ped

for

care

man

ager

s:

regu

lar

rem

inde

rs fo

r G

Ps

on s

ched

uled

te

sts

and

appo

intm

ents

; com

mun

icat

ion

betw

een

patie

nt a

nd s

taff

mem

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; en

sure

adh

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ce to

evi

denc

e-ba

sed

guid

elin

es; e

valu

atio

n of

clin

ical

out

com

es

Latv

ia

Gen

eral

prim

ary

heal

th c

are

syst

em

Notspecified

Pla

ns to

sec

ond

nurs

es to

w

ork

with

GP

in c

hron

ic

care

; edu

catio

n ab

out s

elf-

man

agem

ent;

heal

th p

rom

otio

n an

d di

seas

e pr

even

tion;

de

velo

pmen

t of h

ome

heal

th

care

Qua

lity

crite

ria fo

r ge

nera

l practitionersaredefinedbylaw;

thes

e in

clud

e in

dica

tors

on

the

perio

dic

asse

ssm

ent o

f pat

ient

s w

ith c

ondi

tions

suc

h as

ast

hma

or

diab

etes

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Lith

uani

a

Impr

ovin

g in

ters

ecto

ral

colla

bora

tion

Rou

tine

asse

ssm

ent o

f pro

blem

s an

d ac

com

plis

hmen

ts; a

cces

s to

ps

ycho

soci

al re

habi

litat

ion

serv

ices

in

som

e ca

ses

(men

tal h

ealth

)

Case-findingbynurse;case

man

agem

ent p

ilot (

HIV

/AID

S,

som

e m

enta

l hea

lth p

robl

ems)

Acc

ess

to s

peci

alis

t exp

ertis

eN

ot d

ocum

ente

d

Clin

ical

gui

delin

esR

outin

e as

sess

men

t of c

linic

al

indi

cato

rs

Dev

elop

men

t of i

ndiv

idua

lized

ca

re p

lans

com

mon

for

diab

etes

an

d de

pres

sion

, req

uire

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r ca

rdio

vasc

ular

dis

ease

(Evi

denc

e-ba

sed)

clin

ical

gu

idel

ines

; pro

vide

r ed

ucat

ion

in

case

s (fo

r ex

ampl

e, d

epre

ssio

n)

with

sup

port

from

priv

ate

sect

or

(pha

rmac

eutic

al c

ompa

nies

); ac

cess

to s

peci

alis

t exp

ertis

e

Ele

ctro

nic

book

ing

syst

ems

pilo

ted;

pr

ovid

er fe

edba

ck o

n se

rvic

e de

liver

y th

roug

h da

taba

se h

eld

by te

rrito

rial

patie

nt fu

nd (S

VE

IDR

A)

Table

3.5

co

ntd


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Net

herla

nds

Mat

ador

dis

ease

m

anag

emen

t pr

ogra

mm

e

Acc

ess

to D

iabe

tes

Inte

ract

ive

Edu

catio

n P

rogr

amm

e (D

IEP

), co

mpr

isin

g lif

esty

le in

terv

entio

n tr

aini

ng c

ompo

nent

for

prov

ider

s to

en

gage

pat

ient

s in

the

deve

lopm

ent

of tr

eatm

ent p

lan

and

goal

s; D

IEP

w

ebsi

te; s

yste

mat

ic p

atie

nt fo

llow

-up

Stratificationofpatientsinto

thre

e le

vels

of c

are

inte

nsity

and

cl

inic

ians

(GP,

dia

bete

s sp

ecia

list

nurs

e, e

ndoc

rinol

ogis

t); s

taff

rolesclearlydefined;specialist

diab

etes

nur

se li

aiso

n be

twee

n ho

spita

l and

prim

ary

care

for

all p

atie

nts;

regu

lar

core

team

m

eetin

gs

Use

of M

atad

or p

roto

col;

acce

ss to

spe

cial

ist e

xper

tise

with

end

ocrin

olog

ist s

uper

visi

ng

spec

ialis

t dia

bete

s nu

rse

and

actin

g as

con

sulta

nt to

GP,

plu

s tr

aini

ng

Not

inte

grat

ed; d

ata

on p

atie

nt c

onta

cts

and

outc

omes

col

lect

ed o

n G

P a

nd

hosp

ital i

nfor

mat

ion

syst

ems

Prim

ary

care

gr

oup

ZiO

(M

aast

richt

–H

euve

lland

)

Reg

ular

che

ck-u

ps th

at in

clud

e ed

ucat

ion

on s

elf-

man

agem

ent

by p

ract

ice

nurs

es/s

peci

aliz

ed

diab

etes

nur

ses,

dep

endi

ng o

n th

e le

vel o

f nee

d

Stratificationofpatientsinto

four

regu

lar

mod

ules

plu

s tw

o m

odul

es fo

r (c

ompl

ex)

prob

lem

s; s

taff

role

s an

d responsibilitiesaredefined;G

P

over

sees

refe

rral

to s

econ

dary

ca

re a

nd e

nsur

es fo

llow

-up

Nationallydefinedstandardsfor

diab

etes

car

e an

d m

ultid

isci

plin

ary

care

pro

toco

l; re

ferr

al c

riter

ia

to o

ther

car

e pr

ovid

ers;

inte

rnis

t ac

ts a

s co

nsul

tant

to s

peci

aliz

ed

diab

etes

nur

se o

n pa

tient

s w

ith

(com

plex

) pro

blem

s

Disease-specificelectronicpatientrecord

(Med

ix) c

onta

ins

chec

k-up

and

refe

rral

s da

ta w

ithin

car

e pr

ogra

mm

e, a

llow

s fo

r in

form

atio

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arin

g an

d au

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linke

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Str

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Del

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eds

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divi

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s an

d th

eir

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writ

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co

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ses

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trok

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tient

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th

eir

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Sha

red

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deve

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ove

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pr

ofes

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and

repr

esen

ting

26 s

ocie

ties

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stitu

tions

dea

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with

str

oke

patie

nts;

spe

cial

sta

ff tr

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Ele

ctro

nic

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cord

Por

tavi

ta

Str

oke

Ser

vice

: per

mits

doc

umen

tatio

n an

d sh

arin

g of

info

rmat

ion;

trac

king

an

d re

gist

erin

g of

med

icat

ions

; re

ques

ting,

pla

nnin

g an

d re

gist

erin

g of

(com

plem

entary)examinations;w

orkflow

su

ppor

t


Nam

eS

elf-

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eliv

ery

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Net

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are

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ared

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cqui

re

self-

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ompe

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thro

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task

-orie

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co

mm

unic

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n; m

otiv

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inte

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s an

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early

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are,

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vas

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Mul

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nece

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ata

as p

art o

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k m

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p le

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Sw

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care

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wor

kIn

form

atio

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ater

ial;

cust

omiz

ed

face

-to-

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f-m

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t ed

ucat

ion

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follo

w-u

p; re

gula

r as

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men

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Cleardefinitionofstaffrolesand

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; dev

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are

plan

s; s

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uled

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w-

up in

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leas

t onc

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year

Car

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ols

are

deve

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tern

atio

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iss

guid

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es; s

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alis

t ph

ysic

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are

invo

lved

in th

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ogra

mm

e

Sha

red

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tron

ic m

edic

al re

cord

pe

rmitt

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atio

n sh

arin

g am

ong

heal

th p

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ssio

nals

(cus

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ized

ac

cess

); in

clud

es a

n el

ectr

onic

boo

king

sy

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Bre

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ance

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athw

ay,

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anne

U

nive

rsity

H

ospi

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anne

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Writ

ten

info

rmat

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regu

lar

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fthepatient’s

situ

atio

n; s

hare

d de

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akin

g;

supp

ort b

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aine

d nu

rses

and

so

cial

wor

kers

; pos

sibl

e ac

cess

to

peer

sup

port

gro

ups

Det

aile

d de

scrip

tion

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linic

al

path

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; reg

ular

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st

aff a

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pla

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; re

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im

plem

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Ada

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ovid

er e

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tion

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hysi

cian

s an

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invo

lved

in th

e pr

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mm

e; h

ospi

tal s

peci

alis

ts

are

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ely

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grat

ed in

the

prog

ram

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furt

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thro

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writ

ten

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tatio

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g ca

re p

athw

ay

Dat

abas

e an

d bi

oban

k; p

rovi

ders

fe

edba

ck o

n de

lays

, num

ber

of n

ew

case

s pe

r m

onth

, vol

ume

of re

oper

atio

n,

or fr

eque

ncy

of a

giv

en s

urge

on a

ctin

g as

mai

n op

erat

or in

rela

tion

to th

e to

tal

num

ber

of b

reas

t can

cer

oper

atio

ns

Table

3.5

co

ntd


Nam

eS

elf-

man

agem

ent

sup

po

rtD

eliv

ery

syst

em d

esig

nD

ecis

ion

sup

po

rtC

linic

al in

form

atio

n sy

stem

s

Net

herla

nds

cont

d

Del

ta p

hysi

cian

ne

twor

k, G

enev

aR

egul

ar in

form

atio

n (tw

o in

form

atio

n le

tter

s pe

r ye

ar),

deta

iling

prov

isio

ns fo

r ac

cess

to

hea

lth p

rom

otio

n an

d di

seas

e pr

even

tion

cons

ulta

tions

and

ac

tiviti

es; w

ebsi

te

Prim

ary

care

phy

sici

ans

act a

s ga

teke

eper

s to

spe

cial

ist c

are;

ch

roni

c di

seas

e m

anag

emen

t fo

r di

abet

es, h

eart

failu

re a

nd

asth

ma

unde

r de

velo

pmen

t

Org

aniz

atio

n of

regu

lar

qual

ity

circ

les

for

all p

hysi

cian

s pa

rtic

ipat

ing

in th

e ne

twor

k

Notspecified

Sour

ces:

Austr

ia: S

önni

chse

n, F

lam

m &

Nol

te (2

015)

; Den

mar

k: F

rølic

h, Ja

cobs

en &

Kna

i (20

15);

Engl

and:

Nol

te e

t al.

(201

5); E

stoni

a: L

ai &

Kna

i (20

15g)

; Fra

nce:

Che

vreu

l et

al. (

2015

); G

erm

any:

Erle

r, Fu

llert

on &

Nol

te (2

015)

; Hun

gary

: Gaa

l et a

l. (2

015)

; Ita

ly: R

icci

ardi

et a

l. (2

015)

; Lith

uani

a: L

ai e

t al.

(201

5); L

atvi

a: L

ai, K

nai &

Tau

be (2

015)

; the

N

ethe

rland

s: El

issen

et a

l. (2

015)

; Sw

itzer

land

: Pey

trem

ann-

Brid

evau

x et

al.

(201

5).

Not

es: D

MP:

dise

ase

man

agem

ent p

rogr

amm

e; G

P: g

ener

al p

ract

ition

er; B

RAS

S: B

layl

ock

Risk

Ass

essm

ent S

cree

ning

Sco

re; I

T: in

form

atio

n te

chno

logy

; EEP

: éva

luat

ion

des p

ratiq

ues

prof

essio

nnel

les (

eval

uatio

n of

pro

fess

iona

l pra

ctic

e); S

HI:

statu

tory

hea

lth in

sura

nce;

HAS

: Hau

te A

utor

ité d

e Sa

nté

(Nat

iona

l Aut

horit

y fo

r Hea

lth);

INC

a: In

stitu

t Nat

iona

l Du

Can

cer

(Nat

iona

l Can

cer I

nstit

ute)

; RC

P: re

unio

n de

con

cert

atio

n pl

urid

iscip

linai

re (m

ultid

iscip

linar

y te

am m

eetin

g); C

VD

: car

diov

ascu

lar d

iseas

e; C

OPD

: cor

onar

y ob

struc

tive

pulm

onar

y di

seas

e; N

IHFA

: Nat

iona

l Hea

lth In

sura

nce

Fund

Adm

inist

ratio

n; H

IV: h

uman

imm

unod

efici

ency

viru

s; AI

DS:

acq

uire

d im

mun

odefi

cien

cy sy

ndro

me;

DIE

P: D

iabe

tes I

nter

activ

e Ed

ucat

ion

Prog

ram

me;

ZiO

: Zor

g In

Ont

wik

kelin

g (C

are

In D

evel

opm

ent);

DV

D: d

igita

l ver

satil

e di

sc.


within local cancer networks in France. Dedicated staff training tends to be common for those strategies that involve (the delegation of tasks to) non-medical professionals, such as nurses (for example, asthma disease management and diabetes care management programmes in Hungary; IGEA, Leonardo and Raffaello projects in Italy; breast cancer clinical pathway in Lausanne, Switzerland), practice assistants (for example, VerAH care assistant in family practice, Germany) or allied health professionals (for example, therapists in ambulatory after-care of stroke patients in Salzburg, Austria). Physicians acting as coordinators in Austria, Denmark, Germany and Italy are required to undergo additional training; in other settings, this is provided within the framework of continuing medical education (for example, Estonia, France, Hungary).

A number of approaches also provide training in the use of specific programmes designed to support case-finding (for example, care coordination/interface management Styria, Austria; COPA, Coordination & professional care for the Elderly, France). However, overall the use of clinical information systems tends to be the least developed strategy in most approaches. Exceptions include England and Estonia, with both employing standardized, electronic medical records and electronic booking and reminder systems throughout the primary care system.

3.6 Conclusions

In this chapter, we have reviewed the policy context for, and approaches to, chronic disease management in 12 European countries in place during 2009–2011. Countries have sought to create a regulatory and policy framework to respond to chronic disease during recent years. These generally aim to promote approaches that better integrate care and improve coordination between sectors and levels of care, but countries differ with regard to their vision towards controlling and managing chronic disease.

As noted earlier, our review did not attempt to present a comprehensive inventory of all approaches that are being implemented in a given country. Also, as we have focused on published evidence, it is likely that we have missed innovative approaches that are currently being developed or implemented. However, there are a number of general observations that we have identified.

3.6.1 The majority of approaches tend to focus on populations with defined conditions

The most frequently targeted conditions were type 2 diabetes, asthma/COPD, cardiovascular disease (chronic heart failure, IHD, stroke), cancer and mental


health problems. These conditions are typically targeted by means of structured disease management to enhance coordination, which are typically implemented at the national level, or, in decentralized systems, at regional level. There is wide variation in the nature and scope of approaches and the extent to which non-medical staff is involved in care delivery. Commonly, the GP or family physician tends to act as principal provider or “care coordinator”.

3.6.2 There is a trend towards strengthening the role of nurses in care delivery and coordination

The use of nurses in care delivery and coordination is common in systems that have a tradition in multidisciplinary team working (Nolte & McKee, 2008a). Examples include nurse-led clinics and nurse-led case management as established in countries such as England, Italy and the Netherlands. Conversely, the introduction of nurse-led approaches in primary care has remained challenging in systems where primary care is traditionally provided by doctors in solo practices with few support staff. However, there are moves in these countries towards enhanced functions of nurses in care coordination or case management, as, for example, in Denmark, France and Lithuania. Countries are also seeking to strengthen the role of nurses in providing patient self-management support or the delivery of selected medical tasks, although most often such tasks have remained under the supervision of the GP or family physician, such as in Austria, France and Germany.

3.6.3 Approaches that seek to reduce barriers between sectors remain less common

Many of the observed approaches seeking to enhance the care for people with chronic or long-term conditions tend to be implemented within existing organizational and governance structures without necessarily overcoming existing structural or sectoral boundaries. Such approaches may still be effective in enhancing coordination, through, for example, the use of structured referral pathways, but structural barriers between sectors remain, potentially impeding further progress in advancing service delivery towards one better suited to meet complex chronic care needs.

Approaches that seek to more specifically reduce or eliminate these structural or sectoral barriers were less common. Typically, such approaches would focus on managing the primary–secondary care or the secondary care–rehabilitation interface. Examples include some provider networks in France, a range of integrated care contracts in Germany, or the stroke service Delft in the Netherlands as one specific example of an integrated care service. Frequently,


although not always, approaches that perhaps challenge the established ways to service delivery by overcoming sectoral boundaries through, for example, new ways of contracting between funders and providers, were implemented as pilot projects, with the integrated care pilots and the Partnership for Older People Project, both in England, or the improving intersectoral collaboration pilot in Lithuania as examples. The SIKS project in Copenhagen, Denmark, provides an illustration of an integrated care ‘pilot’ that ended following completion of the project phase but that crucially informed policy development for coordinated care approaches across Denmark more widely.

3.6.4 The implementation of approaches frequently involves financial incentives

In a number of countries, the introduction of new approaches to enhance the care for people with chronic conditions involved additional funding in the form of start-up funding to support infrastructural development (for example, administrative structures). These can be targeted at payers, for example, municipalities in Denmark, integrated care pilots in England, or integrated care contracts in Germany, or, in some cases, support providers, such as in the case of provider networks in France.

Typically, however, new approaches would involve some form of financial incentive, most frequently targeted individual providers or physicians, such as within disease management programmes in Austria and Germany, GPs (diabetes care) in Denmark, provider networks in France, care groups in the Netherlands and Italy or GP practices in the England. Incentives for patients are also being used, but these are less common.

3.6.5 Levels of patient and clinician support vary

Patient access is typically granted in line with access to usual care. Many approaches are being implemented in selected geographical regions and may therefore potentially limit access to defined population groups. The majority of approaches provide some form of patient self-management support, although the level and scope of support offered varies. The use of clinical information systems for chronic disease management tends to be the least developed strategy in most approaches.

Chapter 4

Looking aheadEllen Nolte, Cécile Knai, Richard B. Saltman

Chronic disease as a core challenge to health care systems is now firmly on national and international agendas (United Nations General Assembly, 2011; Council of the European Union, 2013; World Health Organization, 2013). In Europe, chronic disease is the greatest challenge to the goal that the EU has set itself of contributing to the achievement of an increase by two years in the number of years spent by the EU population in good health (Council of the European Union, 2013). Achieving this ambition will require effective measures of disease prevention (Novotny, 2008), while also ensuring that those with established illness will be able to participate in society.

We have shown that while policy-makers in European health systems have recognized these challenges, and have acknowledged both the fiscal and social importance of more effectively addressing the requirements associated with chronic and long-term conditions, they often have had considerable difficulty translating this recognition into effective policy programmes (Nolte & McKee, 2008a).

There are several reasons for these continued translational difficulties, but the core challenge is that strategies that would address the complexity arising from the changing burden of disease sit at policy intersections between several different subsystems involving public health, health care and social care, and the wider regulatory framework within which these are embedded. The approaches implemented by countries described in Chapter 3 pursue a wide range of goals, often seeking to simultaneously:

• improve the quality of care and health outcomes for people with complex care needs;

• strengthen primary care and community services, and optimize their interface with secondary care;

• make more efficient use of scarce resources, and reduce spending on health services;


• empower people with chronic and long-term conditions to help define treatment and care modalities.

This list of objectives would be a tall order for any single set of policy innovations to achieve. It is especially difficult to attain where complex care needs created by people with multiple chronic conditions are concerned, the long-term nature of their requirements, alongside the complex set of interests and priorities of those involved in the delivery and financing of care services. These are likely to differ at the different tiers of the system, from the primary process of patient care and the organizational context, to the financing and policy context at system level, each with distinct rationales and perspectives concerning the delivery of health care (Plochg & Klazinga, 2002). Even where innovative approaches addressing the various objectives may be possible, the likelihood of their successful implementation will be determined, to a considerable degree, by the specific political, economic and cultural context within which they are being introduced.

This volume presents the current state of policy thinking across Europe about how to respond to this set of multiple policy objectives. By exploring different approaches in the studied countries, patterns can be identified and their innovative potential and likelihood of success, or indeed failure, noted. It is important to emphasize that strategies to address chronic disease are constantly evolving and this volume could, in the space available, only provide a brief illustration of the many approaches that are being tested and implemented in countries in Europe. It is likely that some approaches presented here will have experienced further modification, roll-out or indeed termination while new strategies will be in the process of implementation at the time of publication of this volume. Further, as we have noted previously, different systems are at different stages of the process and with different degrees of comprehensiveness (Nolte & McKee, 2008c), and evidence presented in this volume confirms this observation. It is against this background that our discussion of the main observations drawn from the presentation of findings has to be set.

4.1 Learning from existing approaches

Our review of approaches seeking to improve the care for those with chronic conditions in Europe found a tendency among countries to implement change within existing provider structures while models that aimed to reduce barriers between providers, institutions or sectors through service redesign were less common. Where such approaches have been implemented, these are likely to be in the form of pilot projects, or, where they form part of routine care, they tended to be confined to a particular locality or region.

75Looking ahead

One such example is the Gesundes Kinzigtal (Healthy Kinzigtal) model of integrated care in Germany (Hildebrandt et al., 2010). Introduced in 2006, the model is considered the only long-term public health and population-based integration approach in Germany. It uses an innovative shared health gain contract between a health care management company, involving a local physicians’ network, and two regional SHI funds in south-west Germany, alongside P4P elements and a share of the company’s profit on the basis of individual provider performance. The approach was associated with a proportionally smaller increase in health care expenditure compared to other regions in the same state, and a comparative saving of 17% of total costs during a four-year period between 2006 and 2010 (Hildebrandt, Schulte & Stunder, 2013).

The Healthy Kinzigtal service delivery model took advantage of start-up funding, a provision made possible by the government from 2004 to encourage selective contracting of SHI funds with individual providers towards the development of more integrated care (Erler, Fullerton & Nolte, 2015). This option created substantial activity, with some 6500 integrated care contracts concluded by 2008, covering a total of around 6% of patients insured under SHI (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, 2012). However, the number of integrated care contracts has remained stagnant since, coinciding with the discontinuation of start-up funding from 2009; for example, during 2008 and 2009, around 20% of contracts were terminated or not renewed because of funding discontinuation. Importantly, an assessment of the experience of integrated care contracts published in 2012 found that although a number of anticipated benefits from integrated care contracts had been met, such as improved patient satisfaction with care, or the ability to enter into selective contracts, others were not, such as cost savings and reduced service use (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, 2012). The Healthy Kinzigtal model did continue, however, and, as indicated previously, showed potential for cost savings. Although there are efforts to roll out this and other models of more integrated care across Germany, overall their uptake has remained slow.

The Healthy Kinzigtal example is not unique to Germany; indeed similar observations can be made for other countries that have examples of successful models of innovative delivery models but have thus far failed to roll out these models more widely (Curry & Ham, 2011). Where the wider diffusion of models has been possible, this typically required some modification of a given approach to enable take up, which might mean that innovative elements may have to be adapted. The Dutch primary care groups may serve as an example for the scaling up of a care model that was developed locally, and which served


to inform the development of a countrywide approach while retaining the core innovative features of the local model, the Matador disease management programme in Maastricht (Elissen et al., 2015).

Innovative components of the Matador model included: a team approach with the diabetes nurse linking primary and secondary care and taking on some of the tasks previously performed by doctors only; the use of protocols setting out the primary responsibilities for three subgroups of patients to a medical specialist (highly complex), a diabetes nurse (intermediate or stable) or the GP and a practice supporter (low complex) and support of self-management. The redesign of the model towards the one implemented in the form of diabetes care groups included a redefining of the role of the GP and of primary care in general, tasked with the primary responsibility for the subgroup of patients with intermediate to complex care needs. Further adaptations included employment by GPs of practice supporters, who may or may not have a nursing background. This implied a different role for the diabetes nurse, who became a consultant for primary care and a caregiver for patients with highly complex care needs. The wider uptake of the programme was further stimulated and facilitated by the introduction of bundled payments. In a similar vein, the SIKS (Integrated effort for people living with chronic disease) project in Copenhagen, Denmark, served to inform the development of disease management programmes for COPD, type 2 diabetes and CVD in the Capital Region of Denmark (Frølich, Jacobsen & Knai, 2015).

Against this background, it is apparent that, to elevate innovative models of service delivery that provide promising results to a level beyond pilot project or best practice, there is a crucial need for better understanding of specific local conditions that influence the implementation and sustainability of a given approach, so that identified processes can be translated to other contexts and settings. In the context of integrated care in particular, Goodwin (2013) highlighted the need to draw more firmly on implementation science that would enable evidence to be used to support health care policy and practice. It also seems necessary to better understand what Greenhalgh et al. (2004) have referred to as ‘system readiness’ for innovative approaches, that is, the steps that need to be taken to enable wider adoption of new care models. More fundamentally perhaps, there is a need to better understand existing approaches to service delivery to identify those components that present the greatest obstacles to the delivery of high-quality care and that are most likely to act as barriers to change. This issue was highlighted by Epstein and Sherwood (1996); they identified a number of factors for the successful implementation of chronic care management processes, noting that this would require understanding of:

• existing inefficiencies in health care delivery;

77Looking ahead

• disincentives for the patient or the provider to receive or deliver the highest quality care (such as access or cost);

• the relative cost–effectiveness of alternative treatments; and

• the success of different interventions in modifying individual behaviour (for example, adherence).

Lack of understanding of current context, structures and processes, and of the potential for change in the way services are being staffed and delivered to lead to improvement in patient outcomes, might result in the implementation of approaches that are, ultimately, ill-equipped to achieve the desired outcomes. Returning to the example of Germany, among the factors that Amelung, Hildebrandt and Wolf (2012) identified as important barriers to the wider uptake of more coordinated or integrated care approaches within the German health system, the lack of appropriate incentives for key actors to engage in the process was one such barrier. For example, they argued that, for health insurers, the risks to do so currently outweigh the benefits: innovative forms of care typically require investments, yet, stipulations require that where insurers exceed their income (that is, contributions from their members), they have to impose higher premiums on their members, which in turn may threaten their competitiveness in the insurance market. Thus, to encourage insurers to engage in integrated care approaches there may be a need to establish incentive structures that have the potential to better balance the risk–benefit ratio for insurers. Clearly, the specific enablers and barriers for the various actors in the system to engage in change will differ in different settings and it will be important to unpack these various factors in the specific context within which they operate.

In addition to the need to better understand the how and why a given approach works, and its potential for scaling up, there is also a need to better understand the differential impacts of new models of care and what works for whom. We have argued elsewhere how lack of evidence of improved outcomes (however conceptualized) of a given intervention might simply reflect that programme components were not suitable to lead to health improvement in the first place (Nolte et al., 2012b). Likewise, where evidence finds that a given care approach improves outcomes for a subgroup of participants only, this might indicate that the intervention was suboptimal or not sufficiently targeted at those who would benefit most. Indeed, as discussed in Chapter 2, existing research points to the value of targeted approaches to enhance outcomes of people with complex care needs, focusing on those who are most likely to benefit. For example, an evaluation of Dutch primary care groups found that diabetes patients with poorly controlled blood sugar levels saw notable improvements, but there


was little additional benefit for the majority of patients who were already adequately controlled (Elissen et al., 2012). Although these findings require further confirmation (Elissen et al., 2013a), similar observations were reported by a systematic review of diabetes care programmes (Pimouguet et al., 2011).

Likewise, the evaluation of a diabetes disease management programme in Salzburg, Austria, which was implemented as a cluster randomized controlled trial, found only small effects of the intervention on the primary outcome metabolic control (Flamm, Panisch & Sönnichsen, 2012). It concluded that the intervention approach might have taken insufficient account of patient self-management support. Informed by these findings, in a subsequent trial, the patient education module was enhanced through introducing peer support for diabetes patients in the same region (Sönnichsen, Flamm & Nolte, 2015). However, preliminary findings of that trial suggest that the enhanced programme did not significantly improve clinical outcomes, risk profile or quality of life in the intervention group after two years of follow-up (Johansson et al., 2014). Similar to the Dutch primary care groups described earlier, the authors attributed this absence of a significant effect to the observation that both intervention and control groups had already adequate metabolic control, so leaving little room for further substantial improvement.

Overall, these findings point to the need for a more systematic evaluation of new models of care as a means to inform the development of efficient and effective interventions to address the growing burden of chronic conditions in Europe and elsewhere. Evaluation may help identify where a given intervention is likely to lead to inequities in health care delivery. For example, where participation in a novel care approach relies on voluntary enrolment, this might lead to only those with higher health literacy actually benefiting from the programme (selection bias) (Craig et al., 2008). Furthermore, evaluation findings might also highlight issues around programme implementation; for example, where a given intervention is characterized by high drop-out rates of participants this might indicate problems with programme set-up, while also suggesting that the intervention might overall be ill-suited to the needs of the target population.

Arguably, interventions that address the needs of people with chronic conditions should be developed systematically, are based on the best available evidence and appropriate theory, and are tested using a phased approach to inform further development, alongside evaluation. However, as Craig et al. (2008) have pointed out, in practice, interventions emerge from various sources, which may include theory, but may also be based on weak evidence, depending on the drivers behind the intervention. However, even if models and programmes are informed by, say, political imperatives, there are programme design requirements about assessing performance and permitting mid-course corrections that are equally

79Looking ahead

Box 4.1ReportedbarrierstoevaluationinfiveEuropeancountries

In 2010, as part of the DISMEVAL project, we carried out a range of semi-structured

interviews with key informants from Austria, Denmark, France, Germany and the

Netherlands, who were involved in the decision-making process as it relates to various

aspects of chronic disease management in a given health care system context.

Interviews sought, among other things, to explore perceived barriers to developing,

implementing and evaluating chronic care approaches.

Focusing on evaluation, key informants highlighted a lack of overall interest in wanting

to know whether a given innovation does result in improvements in processes or

outcomes. This reluctance can be driven by a range of factors. For example, in

Germany, until recently, SHI funds (commonly referred to as sickness funds), which offer

structured disease management to their enrolled population, received additional funding

for every patient registered in a disease management programme (Erler, Fullerton

& Nolte, 2015). As a consequence, for those SHI funds that have a high proportion

of members with chronic disease, there may have been low interest in identifying

whether or not disease management works because of the risk of losing this additional

funding. Yet, conversely, for those SHI funds with a high proportion of relatively healthy

members,whobenefitedlessfromthefinancialincentive,proofofDMPeffectiveness

was equally undesirable:

There were clear political reasons. [...] So for some sickness funds it was a very

attractive idea to have DMPs because they had more chronic[ally] ill patients who are

eligible for those programmes. They earned a lot of money [from this system]. [...] Other

sickness funds [...] calculated that they would lose a lot of money because they had

not so [many registered] chronic[ally] ill patients. [...] And those sickness funds tried to

stop the programmes on a political basis.[...] This was a big battle. They wanted to stop

the connection of those DMPs to the RSA [risk structure compensation scheme], so

they had no interest in proof of success of those programmes. And this is a big political

issue (Germany).

Other informants from Germany highlighted a historical lack of interest among funders

in “what is done with their money” although this has changed over the years, with an

increasing “consensus about the necessity to have evaluation of the effectiveness of

money spent by the State or by the sickness funds”.

important if programme outcomes are to match expectations. Elsewhere, we have shown that countries can face considerable barriers to the systematic evaluation of new care models (see Box 4.1), reflecting, to considerable extent, lack of evaluation culture and related shortage of capacity as well as a reluctance of payers or providers to engage in evaluation (Knai et al., 2013).


4.1.1 Incorporating the patient perspective

A growing body of evidence points to the potential benefits of actively involving patients with chronic conditions in their own care (Wagner, 1998; Holman & Lorig, 2000). Supporting self-management has been associated with more appropriate use of health services and the potential to improve health outcomes, although the precise benefits will vary according to the conditions involved (Coulter, 2006; Rijken et al., 2008). The concept of active engagement has a

Box 4.1 contd

Several key informants also pointed to a perceived or real reluctance of providers in

supporting evaluation, for example, as a result of the additional administrative burden

this entails. There may be uncertainties about the range of relevant indicators and the

feasibility to collect them, alongside questions, among providers, about the validity of

metrics used for evaluation; such metrics were commonly perceived as not necessarily

representing the true quality of care provided. This notion was reported in several

countries, with interview participants noting that making available such data (for

example, to health insurers) may be interpreted by providers as a compromise on their

freedom of practice to the extent that this would likely involve subjecting their practice

to more external scrutiny:

[...] some doctors [say] that they don’t want to collect data because they are afraid

about the ‘big brother’ syndrome, [...] of being judged on their data. In Denmark there

are many small units of GPs: one-third of GPs are alone in their own practice and

therefore it is easier to blame them if the data are not good enough (Denmark).

This reluctance of physicians to disclose patient data and outcomes to payers and

otherstakeholdersmayalsoreflecttheimportancethatprovidersassigntotheir

professional independence. The underlying concern seems to be that if treatment and

outcomes are made transparent this might interfere with the doctor–patient relationship

and thus impact on patient care.

Against this background, respondents highlighted the need to engage clinicians in the

process more actively so as to come to a common understanding about the purpose of

the evaluation, and thereby strengthen support, as noted for Germany:

Ambulatory [care] physicians have a lot of work with these DMPs, about the evaluation.

They have to give a lot of information but this information is more or less used for

regulatory purposes [only] and is not a good feedback for the practices. For example,

they don’t know what happens to the patient, they have got very bulky reports. [...]

They are not very happy that they have to write a lot of data, a lot of work with that, and

the results of the evaluation are not quite transparent and usable. (Germany)

Source: Knai et al. (2013)

81Looking ahead

persuasive appeal, building on the notion of what Dieterich (2007) referred to as the “modern patient”, who has a legal or moral right to autonomy and self-determination and who can, with the appropriate knowledge and information, make decisions and help improve the system through making informed choices (Greenhalgh, 2009). However, as Bate and Robert (2006:307) observed “[i]n most countries, despite the longevity of the “patient involvement” concept, health care systems are still not putting patients first”. Indeed, as we have shown in Chapter 3 in relation to self-management support for people with chronic conditions, the implementation of such approaches in practice remains weak (Elissen et al., 2013b). Although patient support has moved beyond the mere distribution of information materials towards those that provide access to coaching, lifestyle intervention training and counselling techniques, as well as lay-led programmes, such as the Expert Patients Programme in England, the extent to which these support mechanisms reach wider groups of patients in practice is often unclear.

Experiences of the diabetes disease management programme in Salzburg, Austria, cited earlier point to the challenges of self-management support programmes in demonstrating evidence of effect on clinical outcomes (Johansson et al., 2014). Systematic reviews of self-management support interventions for people with chronic disease have pointed to some improvements in selected outcomes, such as self-efficacy (Foster et al., 2007), or moderate improvements in a range of symptoms such as pain, fatigue, health distress, as well as self-rated health and health-related quality of life, but these were often short-term only and their clinical relevance remains uncertain, as does their impact on service use (Franek, 2013; Kroon et al., 2014). There are many possible explanations for the apparent failure of self-management support programmes to lead to sustained improvement in outcomes; examples include that the length of the evaluation, typically of around 12 months, might be insufficient to demonstrate tangible change in health outcomes, or indeed, resource use (Nolte et al., 2012b). Reflecting on our discussion in the preceding section, it is also likely that programme design may have been inadequate to lead to the desired effect, because it was too narrowly focused and reliant on the clinical setting, and targeted those groups which were less likely to benefit.

An evaluation of the Dutch primary care groups provides further illustration of this point (Elissen et al., 2013b). It found that although Dutch guidelines for type 2 diabetes (care standard) stipulate that patients should play a central role in their care, the practice of diabetes care has remained highly paternalistic. Thus, in its current format, the care group motivates providers to deliver highly standardized care based on performance indicators as stipulated in the national diabetes care standard (Nederlandse Diabetes Federatie, 2007). These


indicators, which are monitored by health insurers, prescribe a defined intensity of service delivery, regardless of patients’ health, demographic or social status. Although frequent monitoring was shown to be especially useful for improving clinical values in poorly controlled diabetic patients, patients in relatively good health could be managed equally effectively in a less physician-guided way that emphasizes self-management. The authors thus argued that there was potential for a more tailored approach to disease management that proactively considers patient characteristics in determining care processes, including self-management support, benefiting a relatively healthy population of diabetic patients for whom intensive monitoring may be inappropriate (Elissen et al., 2012).

Importantly, however, there is a need for initiatives seeking to support people with chronic conditions to self-manage to account for the social and cultural context and norms within which they live (Greenhalgh, 2009). Chronic illness confronts patients with a spectrum of needs that requires them to alter their behaviour and engage in activities that promote physical and psychological well-being, to interact with health care providers and adhere to treatment regimens, to monitor their health status and make associated care decisions, and to manage the impact of the illness on physical, psychological and social functioning (Clark, 2003) This means that any intervention seeking to support people with chronic conditions to self-manage will have to consider their changing needs over time, in particular where they have multiple care needs. Thus, increasing responsibility taken by patients for self-management can create particular challenges for those with multiple conditions, as they may experience aggravation of one condition by treatment of another. For example, a patient with chronic respiratory disease may struggle to adhere to exercise programmes designed for their diabetes (Bayliss et al., 2003). Furthermore, as we have argued previously, patients vary in their preferences for care and the importance they place on health outcomes (Nolte & McKee, 2008a). While the ability of patients to develop individualized treatment plans will be of critical importance to aide effective care, this is unlikely to be sufficient when patients are not considered partners in a care process that is sensitive to the contexts within which people make decisions (Dubois, Singh & Jiwani, 2008).

Failure to take account of patient preferences may lead to suboptimal outcomes of an otherwise innovative service delivery model that seeks to enhance patient care. An illustrative example is that of the national integrated care pilot programme in England, which was carried out from 2009 through to 2011 as described in Chapter 3 (Nolte et al., 2015). A three-year evaluation of six of the 16 pilot sites that used intensive case management for older people at risk of emergency hospital admission, found that staff involved in the delivery of

83Looking ahead

the care believed that the quality of patient care had improved, while patients receiving care in the pilots reported that they found it significantly more difficult to see a doctor or nurse of their choice and felt less involved in the decisions about their care (Roland et al., 2012). Although it is difficult to say whether these perceptions were linked to the change in service delivery as such, this observation highlights that patients need to be consulted on what they actually need and how new delivery models are to be structured to be acceptable to patients and so more likely to be successful. Patient preferences, rather than expert determinations, will need to drive policy formulation.

This latter point is receiving increasing attention under the notion of “experience-based co-design”, which is being tested in patient safety initiatives (Bate & Robert, 2006). It goes beyond mere consultation using user views and perceptions collated through focus groups, patient surveys and other feedback mechanisms. Instead, it is conceived as a joint venture that involves users and professionals working together and throughout the change process as co-designers of a service, based on the experiences of patients (and professionals). This concept has been tested in the area of cancer care (Tsianakas et al., 2012), and may present a useful way forward for improving service design for people with chronic conditions.

4.2 Providing the (regulatory) context to enable innovation

We have previously noted that the policy context within which services are being designed and delivered will be crucial to encourage innovation (Nolte & McKee, 2008c). One area of tension we highlighted was the need to strike a balance, in a given country context, between centrally defined requirements and local autonomy. For example, the creation of a strict national regulatory framework for disease management in Germany has been viewed as beneficial in ensuring that disease management programmes meet an appropriate standard, but it has also been challenged on grounds that it might impede further improvements that take account of local circumstances (Siering, 2008). Tensions also arise in relation to weighing top-down versus bottom-up approaches. Actors operating at the different levels of the health care system are faced with different pressures and consequent priorities that are not necessarily compatible or may even be contradictory (Plochg & Klazinga, 2002). There are particular challenges for organizations that arise from policies initiated by health care reformers on the one hand and established ways of delivery, on the other, which are likely to result in a gap between policy intent and actual implementation (Ham, 2003). We have observed such tensions in our review of approaches to chronic disease management, highlighting the need to create a policy environment that


Box 4.2 Balancing the gap between policy intent and actual implementation: evidence from the DISMEVAL project

As part of the DISMEVAL project, we sought to further explore the barriers to

successful implementation of chronic care, and ways of overcoming these barriers, by

means of interviews with key informants in a range of countries. These revealed a range

of challenges, such as a perceived failure to integrate risk minimization and disease

prevention along the spectrum of care; the persistence of care fragmentation hindering

better coordination; and a lack of structures suitable to promote proactive engagement

with patients in the management of their own condition. Key informants further

discussed the challenge arising from a perceived mismatch between intent, at national

level, to enhance coordination and integration, and the ability at regional or local level to

translate these ambitions into practice.

For example, in Denmark, the 2007 administrative reform led to the reorganization

of regions and municipalities, giving municipalities more responsibility for health.

Specifically,thereformrequiredmunicipalitiestocontribute20%tohealthcare

funding so as to encourage them to increase preventive services and, ultimately,

reduce hospitalizations. However, it was reported that municipalities lacked a

coherent framework to guide them in their new tasks, as well as support to develop

competencies in health care. There was concern that many of the resulting projects

might not be sustainable and measureable:

[Following the administrative reform] the municipalities had a central place in [solving]

problems of the health care sector. The municipalities [have the responsibility] to create

new health centres [...] [designed to overcome] barriers to coordination [...] [However]

municipalities do not have the competence and knowledge about health care. And

there is no systematic development in this area; [...] it is dependent on learning from the

regional level. [...] [Moreover] the Regions got most of the [earmarked] 600 million DKK.

[...] We have ended up with a lot of different projects and I am not sure how they will

evaluate the projects and […] implement the best. (Denmark)

Such disjoint between intent, at national level, to enhance coordination and integration,

and ability at regional or local level to translate these ambitions into practice was also

reported by French participants. For example, the 2009 reform in France stipulated

that patient education should form a mandatory component of chronic illness care.

However, this stipulation was not accompanied by adequate resources to implement

relevant initiatives on the ground:

Funding for patient education has only got limited or ad hoc financing […] usually

allocated for one year, and then [once the funding runs out] it is always put into

provides the means for those who are asked to implement change to acquire the actual capacity and competence to do so to be critical for success (see Box 4.2).

85Looking ahead

Fundamentally, however, it is important to come to an understanding as to whether approaches to better coordinate care for those with chronic conditions is to be considered as a series of interventions that, by implication, ought to be cost-effective and support financial sustainability. Alternatively care coordination and integration could be interpreted, and evaluated, as a complex strategy to innovate and implement long-lasting change in the way services in the health (and social care) sectors are being delivered and that involve multiple changes at multiple levels. Evidence presented here and elsewhere strongly points to the latter, and initiatives and strategies under way will require continuous evaluation over extended periods of time that will enable assessment of their impacts on both economic and health outcomes. This will mean investment in research alongside investment in the development and implementation of service reconfiguration initiatives to ensure that evaluation will inform service development, in particular if we are to generate appropriate conclusions about programme effectiveness and the application of findings to inform decision-making.

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Box 4.2 contd

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The rising burden of chronic illness, in particular the rapid increase in the number of people withmultiple health problems, is a challenge to health systems globally. Associated premature mortalityand reduced physical functioning, along with higher use of health services and related costs, areamong the key concerns faced by policy-makers and practitioners.

There is a clear need to redesign delivery systems in order to better meet the needs created bychronic conditions, moving from the traditional, acute and episodic model of care to one that bettercoordinates professionals and institutions and actively engages service users and their carers.Many countries have begun this process but it has been difficult to reach conclusions about thebest approach to take: care models are highly context-dependent and scientifically rigorous evaluations have been lacking.

Assessing chronic disease management in European health systems explores some of the key issues, ranging from interpreting the evidence base to assessing the policy context for, and approaches to, chronic disease management across Europe. Drawing on 12 detailed country reports(available in a second, online volume), the study provides insights into the range of care modelsand the people involved in delivering these; payment mechanisms and service user access; andchallenges faced by countries in the implementation and evaluation of these novel approaches.

This book builds on the findings of the DISMEVAL project (Developing and validating DISease Management EVALuation methods for European health care systems), led by RAND Europe andfunded under the European Union’s (EU) Seventh Framework Programme (FP7) (Agreement no. 223277).

The editors

Ellen Nolte, Hub Cordinator, European Observatory on Health Systems and Policies.

Cécile Knai, Senior Lecturer, London School of Hygiene & Tropical Medicine.

Richard B. Saltman, Professor of Health Policy and Management at the Rollins School of PublicHealth of Emory University in Atlanta and Associate Head of Research Policy at the EuropeanObservatory on Health Systems and Policies.

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Edited by

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Cécile Knai

Richard B. Saltman

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