Institut for Statskundskab The Danish strategy for developing better integrated and less expensive long term care services Karsten Vrangbæk Department of Political Science and Department of Public Health University of Copenhagen

Long term care Treatment and care for citizens with chronic or long term somatic or psychiatric care needs Prevention of further functional decline and frailty for people with chronic or long term conditions -> Complex and multidimensional involving many different sectors: health (primary and secondary), social care, care for the elderly etc and different administrative levels

Context Ageing society and increasing number of citizens with chronic care needs (incl multi-morbidity) Structural reform of – Larger regions and larger municipalities with wider responsibilities Centralization and modernization of hospital infrastructure Economic downturn and constrained budgets: Increasing expenditures for health, specialized social care etc.

Ageing society and increasing needs Avg pct54,754,353,953,452,852,351,951,7 65+ Avg pct15,315,615,916,316,817,317,818,2 67+ Avg pct13,313,513,613,914,214,715,215,7

Ageing society and increasing needs Municipal expenditure health per inhabitant avg Municipal expenditure child care per inhabitant avg Municpal expenditure elderly per citizen avg

Ageing society and increasing needs

Structural reform of 2007 General reform of public administration in Denmark Changes in tasks/responsibilities, political/administrative units and financing Health care was a key sector in the reform rhetoric

Structural reform of 2007 Main political arguments: larger municipalities/regions will enable more expertice and more financially robust administration of welfare services (higher volume -> better quality and more efficient administration) To create a unified entry point for citizens through clearer division of labor and better coordination -> A rare ”window of opportunity” due to the combination of reform minded central level politicians, de facto majority government, weak internal and external opposition and reduced support for decentralist ideas

What facilitated the reform? I. Parliamentary situation: Strong government with de-facto majority Change in internal power balance in major government party (from localism to central steering). Coalition party and support party both had a weak power base at the regional/local level II. Creation of an advocacy coalition: ”Danish Industry”, ”Local Government Denmark” and key ministers and ministries (Finance, Economics and Interior) Reduction in number of local governments (and mayorships) outweighed by more tasks, and stronger position

What facilitated the reform? III. Management of the policy process: Tight control of government commission created arguments for change and framed the policy choices Government did not reveal its intentions untill late in the process. This created little scope for resistance from weak opposition and weak association of counties All local/regional government staff guaranteed a job after the reform IV: Macro trends Weaker support for localism and local democracy in the population (from participation to output focus) Strong belief in ”benefits of scale” in specialized health care Concerns about quality and ”sustainability” in smaller municipalities Demographic transition necessitates a stronger emphasis on services for elderly, chronic care patients and multimorbity Long term financing of the welfare state

Structural reform of 2007 MunicipalitiesRegionsState From 271 to 98 municipalities Average size from to inhabitants Only 7 municipalities with less than Political council with directly elected politicians From 13 counties to 5 regions. Capitol region is the largest with 1,6 million inhabitants. Northern Jutland has 0,6 mill inhabitants Regional council with 41 directly elected politicians 5 new regional state administrations replace the previous 14. National Parliament with 179 directly elected politicians

Changes in health care administration Five new regions with specialized health care (hospitals and practicing general and specialist doctors) as the primary task Municipalities play a stronger role in prevention, health promotion and rehabilitation (extensive home care and some health centres/clinics w/o medical personnel)

Changes in financing of health care Removing regional taxation State block grants and some activity based funding Municipal co-funding

Financing of regional HC after 2007 State block grants (75%): based on socio demographic criteria State activity based funding (5%): Based on DRG system. Paid out after threshold/baseline is reached Municipal co-funding (20%): 34% of DRG rate for hospital care 30% of rate for general and specialist practice 70% of rate for rehabiliation in hospitals Maximum levels specified for each episode and at macro level

Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Indsæt” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato og ”Enhedens navn” i Sidefod Enhedens navn Sted og dato Dias 15 Source: European Observatory on Health Systems. HiT report

Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Indsæt” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato og ”Enhedens navn” i Sidefod Enhedens navn Sted og dato Dias 16 OECD Health Data 2014

Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Indsæt” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato og ”Enhedens navn” i Sidefod Enhedens navn Sted og dato Dias 17 OECD Health Data 2014

Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Indsæt” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato og ”Enhedens navn” i Sidefod Enhedens navn Sted og dato Dias 18 OECD health data 2014

Instruments for policy coordination and integration of care after 2007 State and regions/municipalities Budget law and annual agreements b/n municipalities/regions and government. - Determine expenditure targets and tax levels. Provide an arena for negotiating new policy initiatives Regions and municipalities Health agreements entered between regions and municipalities in every election term (4 years) Structure of joint committees and working groups locally and regionally Supported by national guidelines, standards and indicators for monitoring progress

3rd generation health agreements Mandatory topics: 1.Prevention 2.Treatment and care (admission and discharge procedures) 3.Training and rehabilitation 4.Health IT and work processes General issues: Division of labor Knowledge sharing and training Coordination of capacity Involvement of patients and relatives Equity in health care Documentation, research, quality development and patient safety

National indicators for health agreements Readmissions/preventable readmissions Acute medical short term admissions Patients waiting for discharge after treatment Waiting time for diagnosis for child and adolescent psychiatry Waiting time for rehabilitation Share of specialized/standard rehabilitation plans Number of rehabilitation plans by diagnosis, municpality and hospital Patient experienced colloboration and communication Implementation of eHealth standards for municipalites/hospitals More to follow….

Integration of care: Patient pathway programs and standards (across specialized and primary care) Cancer, heart diseases, Diabetes, COPD etc, prevention National Agency for Health and Medicines -Steering group for chronic care -Developed a generic chronic care pathway model in 2008 (most recent version 2012) based on ”Chronic care model” -Diabetes as the first specific pathway program. – Now also COPD, -Experiments with models for ”pathway coordinators” across regions and municipalities. – Formalizing the responsibility for information exchange and guidance

Integration of care: E-health (communication and information sharing) E-referrals and prescriptions (all GPs, pharmacies and hospitals) Integrated portal for patients and professionals: Sundhed.dk Electronic patient records National e-medicine card

Integration of care Regions Major national investment scheme New hospitals in all regions - closing old hospitals Reorganizing acute care functions Reorganizing along patient pathway functions Regional/municipal activities Municipal/regional units (e.g TUE at BBH) Follow home arrangements Co-location in health centers Telemedicine (250+ projects) Support and training of municipal staff

Municipal integration of care: Municipal efforts to integrate home care, rehabilitation, prevention, social care, employment services etc Home care: Sustaining citizen functionality in own home for as long as possible (new types of rehabilitation based on a holistic assessment of patient functionality at home/in society) Medical devices and aids. Personal care, and assisted living Telemedicine, (250+ projects: eg. home based dialysis, IV drug, monitoring COPD, diabetes, ulcers etc.) Innnovative ways of engage with civic society volunteers and relatives Physical exercise, social activities, transport etc.

Municipal integration of care: Local level institutional care: Acute/temporary care (prevent admissions and readmissions, facilitate rapid discharge) Integrated health centers combining prevention, rehabilitation and general support Various types of housing and assisted living facilities for elderly (but elderly typically stay in own home longer)

Regional hospital plans Major national investment scheme New hospitals in all regions Closing down old hospitals Municipal health services Health centers, temporary placement facilities municipal/regional units (BBH)

Does it work? Are LTC services more integrated and cheaper? No comprehensive evaluations. – Methodological and definitional problems.- Data quality Health agreement indicators show some improvement, but data quality issues Health agreements are largely viewed by municipal and regional managers as a useful instrument to create dialogue b/n regions and municipalities. – But concerns about the status of GPs

Does it work? Are LTC services more integrated and cheaper? Survey data show continued high patient satisfaction Municipalities are investing in better health services: training, new rehabilitation programs, temporary acute facilities, health centers etc Many examples of collaborative projects region/municipality (anecdotal evidence) Some clinical quality data - particularly within cancer care - are still trailing other Nordic countries. – But lifestyle and historical factors are important.

Does it work? Are LTC services more integrated and cheaper? No comprehensive evaluations. – Methodological and definitional problems.- Data quality Health agreement indicators show some improvement, but data quality issues Health agreements are largely viewed by municipal and regional managers as a useful instrument to create dialogue b/n regions and municipalities. – But concerns about the status of GPs

For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Indsæt” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato og ”Enhedens navn” i Sidefod Byt billede: Ny slide og klik på ikon, indsæt billede Enhedens navn Dias 31 Sted og dato