Pilot Model 1 implementation manual ©2017 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 15 14 13 12 This work is the product of the staff of the World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgement on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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IMPLEMENTATION MANUAL Table of contents Table of figures 4 List of tables 5 List of diagrams 5 Introduction 9 Rationale 12 Service delivery organization model 23 Scope 23 Outpatient rehabilitation 28 Prevention 29 Patients/Enrollees 32 Providers 33 Financing 36 Main assumptions of funding for model 1 36 Costing of the package – sources of funding 38 Costs of the pilot programme: summary 48 Contracting and provider payment mechanism 51 Readiness and capacity building of providers 54 Patient stratification tools 55 Project management and monitoring 58 Monitoring and evaluation 61 Pilot evaluation indicators 64 Reporting Requirements 75 Information technology 76 Bibliography 81 4 PILOT MODEL 1. IMPLEMENTATION MANUAL Table of figures Figure 1: Share of reported patients, services and costs with selected chronic diseases in primary, ambulatory and hospital care in 2015 13 Figure 2: Share of deaths attributable to non-communicable diseases in Poland 15 Figure 3: Number of visits and patients at the PHC level in 2015 in Poland 16 Figure 4: Number of patients and services at the PHC level in Poland in 2015 – Selected diseases (11) for Model 1 17 Figure 5: Number of patients, services and costs at the OSC level in Poland in 2015 – Selected diseases (11) for Model 1 17 Figure 6: Number of patients, services and costs at the hospital level in Poland in 2015 – Selected diseases (11) for Model 1 18 Figure 7: Share of patient and services relating to selected diseases (11) for Model 1 at the PHC, OSC and hospital level in 2015 18 Figure 8: Costs of selected diseases (11) at the OSC and hospital level as a share of total costs of OSC and hospital care in 2015 19 Figure 9: Patients and services by selected diseases (11) at all three levels of care (PHC, OSC and hospital) in 2015 in Poland 20 Figure 10: Patients, services and costs of selected diseases at the OSC and hospital level in Poland in 2015 20 Figure 11: Number of patients and costs related to selected diseases (11) in OSC and hospital care 2015 21 Figure 12: Costs per 10,000 patients and 10,000 services at the OSC and hospital level in 2015- selected diseases. 21 Figure 13: Costs of selected Outpatient Specialist Care consultations in relation to overall OSC costs 22 Figure 14: Cost of the Model 1 pilot project as % of NFZ (National Health Fund) budget – divided into categories 37 Figure 15: The division of the four-year pilot project costs according to the type of services funded as part of the new capitation 39 Figure 16: Division of pilot project funds of total 42 Figure 17: Resource allocation in the pilot 49 Figure 18: Annual pilot budget – First year 49 Figure 19: Estimation – Model 1 pilot, whole country integrated care vs. NFZ expenditures 50 5 PILOT MODEL 1. IMPLEMENTATION MANUAL List of tables Table 1: Comparing of present healthcare model with proposed model 1 10 Table 2: Number of patients and visits to PHC in Poland (first top 20 causes) 14 Table 3: Scope of competencies of the current primary health care model (PHC) and Model 1 23 Table 4: Scope of prevention of the current primary health care model (PHC) and Model 1 24 Table 5: Scope of diagnostics 24 Table 6: Key organizational features of Model 1 27 Table 7: Interventions in the assessment of the patient’s general health 31 Table 8: Selection criteria for the sample providers 33 Table 9: Availability of medical advice in the WOBACZ study 34 Table 10: Epidemiological data on 11 DMP diseases 41 Table 11: Summary of costs (in PLN) 48 Table 12: Integrated care evaluation domains 67 Table 13: Model 1 outcome indicators 67 Table 14: Pilot Model 1 output indicators 68 Table 15: Indicators of quality of care 68 Table 16: Indicators of coordination 70 Table 17: HIS modules pertinent to the pilot 74 Table 18: Reporting requirements 75 List of diagrams Diagram 1: Financing model for Model 1 47 Diagram 2: Preparation of providers for service delivery 60 Diagram 3: M&E framework 63 Diagram 4: Outcome Indicators 65 6 PILOT MODEL 1. IMPLEMENTATION MANUAL List of abbreviations CHUK – Prevention Program for Cardiovascular Diseases COPD – Chronic obstructive pulmonary disease DEKL – XML message for declarations in PHC and OSC DMP – Disease Management Program DTP – Diagnostic and Therapeutic Path EDM – Electronic Medical Records (Elektroniczna Dokumentacja Medyczna) FFS – Fee-for-Service GDP – Gross Domestic Product GP – General Practitioner GUS – Central Statistical Office (Główny Urząd Statystyczny) HIS – Health Information System IC – Integrated Care IPOM – Individual Medical Care Plan (Indywidualny Plan Opieki Medycznej) ISO – International Organization for Standardization IT – Information Technology M&E – Monitoring and Evaluation MoH – Ministry of Health NFZ – National Health Fund (Narodowy Fundusz Zdrowia) NHS – National Health System NIK – Supreme Audit Office (Najwyższa Izba Kontroli) NIPH-NIH – National Institute of Public Health – National Institute of Hygiene NOCH – Night and Holiday Healthcare OECD – Organization for Economic Co-operation and Development OSC – Outpatient Specialists Care PIU – Project Implementation Unit PLN – Polish Zloty POM – Pilot Operational Manual PHC – Primary Healthcare 7 PILOT MODEL 1. IMPLEMENTATION MANUAL SIMP – System of Information Monitoring in Prophylaxis (System Informatyczny Monitorowania Profilaktyki) SOR – Hospital Emergency Care (Szpitalny Oddział Ratunkowy) SWIAD – XML message for services at the OSC and hospital level TOR – Terms of Reference WHO – World Health Organization ZBPOZ – XML message for consolidated data on services granted under PHC ZIP – Integrated Patient Information System (Zintegrowany Informator Pacjenta) 8 PILOT MODEL 1. IMPLEMENTATION MANUAL Acknowledgments The integrated care models contained in this report were prepared under a RAS (Reimbursable Advisory Services) agreement, signed in November 2015 between the World Bank and the National Health Fund. The work was led by Anna Koziel and Mukesh Chawla (both World Bank), who were assisted by a broad team of subject matter experts, including Adam Kozierkiewicz, Agnieszka Gaczkowska, Zbigniew Król, Artur Prusaczyk, Andrzej Zapaśnik, Aleksandra Kononiuk and Rocio Schmunis. Adrienne Kate Mcmanus and Gabrielle Lynn Williams, both World Bank, edited the final product and assisted with the writing. Gabriel Francis, Zinaida Korableva and Maya Razat provided key support at different stages of the preparation of this product. The authors would like to extend special thanks to Aparnaa Somanathan, Donald Edward Shriber, Mickey Chopra and Shuo Zhang, all World Bank, for their valuable comments and suggestions, which improved the quality of the final deliverable. The report was prepared under strategic guidance and direction of Arup Banerji (Country Director), Enis Baris (Practice Manager), Carlos Piñerúa (Country Manager) and Marina Wes (Country Manager) from the World Bank. The authors would like to take this occasion to record a deep sense of gratitude for Konstanty Radziwiłł (Minister of Health) and Piotr Gryza (Undersecretary of State, Ministry of Health), Andrzej Jacyna (President) and Maciej Miłkowski (Deputy President) of the National Health Fund, for their invaluable advice and support throughout the preparation of these models. This work would not have been possible without their active involvement and strategic oversight. A large number Ministry of Health and National Health Fund staff gave generously of their time and advice, and we are grateful to all of them. In particular, we would like to recognize Dariusz Dziełak, Krzysztof Górski, Damian Jakubik, Katarzyna Wiktorzak, Sabina Karczmarz, Katarzyna Ilowiecka, Dariusz Jarnutowski, Katarzyna Klonowska, Rafał Kiepuszewski, Rafał Kozłowski, Katarzyna Kulaga, Iwona Poznerowicz, Agata Szymczak, Milena Sześciórka-Rybak, and Andrzej Śliwczyński for always being available. The models were designed in a process of consultation and discussion with a community of experts as well as medical and patient communities. We would like to thank the following for their active participation, comments and ideas: Ewa Bandurska, Mariusz Bidziński, Michał Brzeziński, Jarosław Buczyński, Czesław Ceberek, Aneta Cebulak, Damian Chaciak, Ewa Dmoch-Gajzlerska, Przemysław Dybciak, Adam Dziki, Dawid Faltynowski, Dariusz Gilewski, Grzegorz Gierelak, Piotr Głuchowski , Jacek Gronwald, Barbara Grudek, Marika Guzek, Bartosz Idziak, Marek Jankowski, Monika Jastrzębska, Małgorzata Kalisz, Piotr Kulesza, Tomasz Kobus, Anna Kordowska, Donata Kurpas, Anna Miecznikowska, Jeremi Mizerski, Jolanta Michałowska, Włodzimierz Olszewski, Tadeusz Orłowski, Iwona Orkiszewska, Ewa Orlewska, Bartłomiej Ostręga, Michał Pękała Bartosz Pędziński, Jarosław Reguła, Jarosław Skłucki, Agnieszka Sowa, Andrzej Strug, Sylwia Szafraniec-Buryło, Joanna Szeląg, Roman Topór-Mądry, Jan Tumasz, Piotr Tyszko, Adam Windak, Andrzej Witek, Wiesław Witek, Mikołaj Wiśniewski, Tomasz Włodarczyk, Joanna Zabielska-Cieciuch, Marzena Zarzeczna-Baran, Tomasz Zieliński, and Paweł Żuk. Finally, we would like to recognize participants of numerous meetings and conferences during which solutions proposed within the framework of the models were openly discussed. We have learned a lot throughout this process, and have hopefully done justice to all the suggestions that we have received during the preparation of this report. 9 PILOT MODEL 1. IMPLEMENTATION MANUAL Introduction The expanded primary health care “Model 1” covers the original scope of primary healthcare (POZ); selected services provided by ambulatory specialist care (AOS). Additionally, it offers broader competencies to the primary care team of general practitioners, nurses, midwifes, and optionally, physical therapists (optional). The model’s primary objective is to enhance and strengthen’ service delivery to health needs of the covered population through high quality services, actively providing health care to citizens regardless of their health status and in a comprehensive way, combining preventive measures with curative care. The following features are included in Model 1: 1 implementation is carried out in a comprehensive, planned, sustained and integrated manner; 2 offering pro-active healthcare to patients, where appointments in the clinic are initiated not only by the patient but also by service provider. The patient and his/ her family are active partners of the medical personnel in joint decision-making regarding actions in sickness and in health based on a jointly developed individual medical care plan (IPOM), and; 3 not limiting a patient’s right to choose a clinic, but offering real choices of organizations during the treatment process. Model 1 is designed as a purposeful collaboration between the general practitioner and primary health care (PHC) team, including physical therapists and expert consultants. The desired outcome is the decentralizing of competencies to the lowest possible effective level and creating open communication between medical all practitioners, patient and his family. This enhanced communication structure is supported by IT systems designed to facilitate the exchange of information about historical and planned medical events, and storing medical records electronically. 10 PILOT MODEL 1. IMPLEMENTATION MANUAL Introduction The Population-based approach to the healthcare is an integral part of this model as it addresses determinants of health and recognizes that they are complex and interrelated. The model is financed through incentives that guarantee optimal allocation of funds to healthcare services. Both the payer and medical organizations monitor the quality of healthcare and its cost-effectiveness based on indicators developed during the pilot stage. A very important element of M&E activities will be the public dissemination of data, analysis and knowledge gained through monitoring activities. This will strengthen not only the transparency of the intervention but also their effectiveness through wider dissemination of the findings of the evaluation. Table 1: Comparing of present healthcare model with proposed model 1 Present healthcare model Model 1 Service focused Needs focused Quantity driven Quality Driven Reactive and responsive Proactive and preventive Incidental and acute Planned and sustained Selective and fragmented Comprehensive and integrated Passive, uninformed and dependent patient Active, informed and empowered patient Medical professionals working individually Medical professionals working collaboratively Centralization of competencies to higher Decentralization of competencies to lower healthcare levels healthcare levels Low technological support Technology as a support and facilitator of healthcare provision Focused on individual’s health Focused on population health Supply driven – Patients utilize available service Demand driven – Patients choose their healthcare provider Reduces incentives by poorly designed Increases incentives by well-designed financing financing Little monitoring of service quality Robust monitoring of service quality 11 PILOT MODEL 1. IMPLEMENTATION MANUAL Introduction The key expected results from the organizational and financial changes introduced during Model 1 pilot stages are: 1 broader spectrum of primary healthcare services for the patient and; 2 coordinated healthcare and prophylactic innervations to deal with the patient’s most serious health issues. 3 Tools to strengthen integrations and coordination at the patients, healthcare provider and payer level will be introduced. Assumptions used in the model are generated from lessons learned during implementation of small-scale primary care model in various regions in Poland, and experiences of countries where similar solutions have been adopted. This Pilot Operational Manual (POM) is designed to aid the National Health Fund (NFZ) implement the Model 1 pilot, and to serve as a guide to plan and manage the pilot activities as per the pilot development objectives. The POM is intended to ensure consistency, coordination, and coherence in pilot operations across the various components, and clarity, transparency and accountability on the part of those involved in managing, implementing and monitoring the pilot. The POM tasks include: ■■ Rationale and background data supporting the Model ■■ Description of the scope of the services under Model 1 ■■ Financing model ■■ Additional relevant information for implementation 12 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale (methodology for selecting scope of diseases under model 1) The key sources informing the methodological approach to disease inclusion come from epidemiological data on key health issues in Poland contained in various editions of the NIPH-NIH report “Health Status of the Polish Population”, together with the competencies of family physicians described by the Kolegium Lekarzy Rodzinnych w Polsce (College of Family Physicians in Poland), covered in the textbook, Medycyna Rodzinna (Family Medicine) edited by professor A. Windak. The first assumption is that the initial phase of the pilot project, geared to develop and test new tools for the integrated care system, begins with a realistic expansion of the range of diagnostic problems and chronic diseases. From consultations with health care professionals, a list is generated of the most frequent diseases diagnosed at the primary care level. The review NFZ data and the literature, found in the reference list, show that disease areas identified by the medical community reflect greater epidemiological problems prevailing in the population. The generated list of diagnosed diseases is cross-referenced with data reported to the NFZ by selected specialist outpatient care providers (OSC) across the country. The outcome confirms primary health care trends in disease reporting; the selected chronic diseases account for 41% of services in neurology clinics, and 84% in endocrinology clinics. Of specialist services provided by these clinics, the average share of consultations relating to 11 diseases for all clinics under review was 66% of all consultations. At the national level, services treating the 11 most frequently reported diseases in the reviewed clinics cost over PLN 770 million, which is approximately 14% of the total specialist outpatient care budget (approx. PLN 5.6 billion). Based on data analyses, review, and feedback from providers, the list of chronic diseases covered by the Model 1 pilot project during the first year of the pilot is specified as follows: ■■ Primary hypertension ■■ Type 2 diabetes ■■ Chronic coronary artery disease ■■ Permanent atrial fibrillation ■■ Chronic heart failure ■■ Asthma ■■ Chronic Obstructive Pulmonary Disease COPD 13 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale ■■ Parenchymal goiter and thyroid nodule ■■ Hypothyroidism ■■ Peripheral osteoarthritis ■■ Back pain At present, these diseases are only partially treated at the PHC level, remaining for the most part treated at the specialist care level. A prediction under Model 1 implementation, is that many patients currently treated at the specialist care remain with their family doctor for treatment. Figure 1: Share of reported patients, services and costs with selected chronic diseases in primary, ambulatory and hospital care in 2015.1 60.0% 54.2 50.0% 40.0% 40.8 30.0% 24 20.0% 19 17.65 15.43 14.96 11 10.0% 0.0% PHC OSC Hospital Share of patients Share of services Share of costs Source: World Bank own analysis based on NFZ data from 2015 Due to the specific financing system of PHCs based on capitation, it is impossible to calculate PHC expenditure related strictly to 1 the 11 disease chosen for the analysis. 14 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale Table 2: Number of patients and visits to PHC in Poland (first top 20 causes) Share of consultations Avg per 1000 inhabitants Avg no. of consultations per capita No of patients (thousands) Number of consultations (thousands) ICD_10 Hypertension 17.101 6.456 2.65 445 11.72% Persons in contact with health services in other circumstances 16.537 7.235 2.29 430 11.34% Acute upper respiratory tract infection 7.403 5.133 1.44 192.5 5.08% Acute Nasopharyngitis (common cold) 6.617 4.344 1.52 172 4.54% General medical examinations of people without symptoms 5.133 3.477 1.48 133.5 3.52% and diagnosis Persons contacting health service to receive consultation and advice 4.691 2.639 1.78 122 3.22% other than classified elsewhere Medical observation and evaluation of cases suspected of having 3.865 2.881 1.34 100.5 2.65% a disease or similar condition Acute inflammation of the throat 3.410 2.642 1.29 89 2.34% Insulin independent diabetes 3.277 1.406 2.33 85 2.25% Acute bronchitis 3.005 1.955 1.54 78 2.06% Disorders of spinal nerves and the nerve plexus 2.826 1.783 1.58 73.5 1.94% The need for combined prophylactic vaccination against several diseases 2.137 1.578 1.35 55.6 1.47% Chronic ischemic heart disease 2.096 9.61 2.18 54.5 1.44% Hypertensive heart disease 1.914 8.05 2.38 50 1.31% Degenerative changes to the spine 1.697 1.174 1.44 44 1.16% Acute tonsillitis 1.676 1.306 1.28 43.6 1.15% Research and services for administrative purposes 1.675 1.309 1.28 43.6 1.15% Alterations in lipids and other lipidemia 1.572 1.062 1.48 41 1.08% Bronchial asthma 1.447 736 1.96 37.6 0.99% Control tests after the treatment of diseases other than malignant 1.205 816 1.48 31 0.83% tumours Source: NFZ data, 2015 15 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale In total, the selected 11 diseases constitute over 50% of all chronic diseases reported at the primary health care level and over 40% of ambulatory health care. The list of the chronic diseases covered by Model 1 may extend during the process of pilot implementation. It is also worth noting that most of the population participating in the Model 1 require only PHC care and disease management; only a small group of the population requires specialized care. Figure 2 presents NCDS level responsible for all deaths in Poland. Figure 2: Share of deaths attributable to non-communicable diseases in Poland 90.15 90.5% 90.0% 89.56 89.21 89.10 89.5% 88.76 89.0% 88.12 88.5% 88.0% 87.5% 87.0% 1990 1995 2000 2005 2010 2015 Source: IHME, 2015 (1) From 2015 data, the highest number of visits (over 17 million visits) and second highest number of patients (almost 6.5 million patients) at the PHC level related to hypertension, the second most frequently reported cause of PHC consultations was general contact with the doctor. Figure 3 presents the main reasons for PHC consultations as illustrated by the number of patients and visits. Rationale Control tests after the treatment of diseases other than malignant tumors Bronchial asthma Alterations in lipids and other lipidemia Research and services for administrative purposes Acute tonsillitis Degenerative changes to the spine Hypertensive heart disease Chronic ischemic heart disease The need for combined prophylactic vaccination against several diseases Disorders of spinal nerves and the nerve plexus Acute bronchitis PILOT MODEL 1. IMPLEMENTATION MANUAL Insulin independent diabetes Acute inflammation of the throat Medical observation and evaluation of cases suspected of having a disease or similar condition Persons contacting health service in order to get consultation and advice other than classified elsewhere Figure 3: Number of visits and patients at the PHC level in 2015 in Poland General medical examinations of people without symptoms and diagnosis Acute nasopharyngitis (common cold) Source: World Bank analysis based on NFZ data, 2015 Acute upper respiratory tract infection the location of myeloma or undetermined Persons in contact with health services in other circumstances Hypertnesion No. of patients No. of visits 18 mln 16 14 12 10 8 6 4 2 0 16 17 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale Figure 4: Number of patients and services at the PHC level in Poland in 2015 – Selected diseases (11) for Model 1 7 mln 20 mln 6 15 5 4 10 3 2 5 1 0 0 Parenchymal goiter and thyroid COPD Permanent atrial fibrillation Chronic heart failure Asthma Hypothyroidism Chronic coronary artery disease Type 2 diabetes Peripherial osteoarthritis Back pain Primary hypertension No. of patients No. of services Source: World Bank own analysis based on NFZ data Figure 5: Number of patients, services and costs at the OSC level in Poland in 2015 – Selected diseases (11) for Model 1 3 mln 250 mln PLN 2.5 20 2.0 15 1.5 10 1.0 5 0.5 0 0 Parenchymal goiter and thyroid Chronic heart failure Permanent atrial fibrillation COPD Chronic coronary artery disease Asthma Type 2 diabetes Primary hypertension Hypothyroidism Peripherial osteoarthritis Back pain No. of patients Costs No. of services Source: World Bank own analysis based on NFZ data 18 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale Figure 6: Number of patients, services and costs at the hospital level in Poland in 2015 – Selected diseases (11) for Model 1 250 thousands 1.6 bln PLN 1.4 200 1.2 1.0 150 0.8 100 0.6 0.4 50 0.2 0 0 Parenchymal goiter and thyroid nodule Hypothyroidism Asthma Chronic Obstructive Pulmonary Disease (COPD) Primary hypertension Type 2 diabetes Permanent atrial fibrillation Back pain Peripheral osteoarthritis Chronic heart failure Chronic coronary artery disease No. of patients Costs No. of services Source: World Bank own analysis based on NFZ data In comparing the three levels of health care, PHC, OSC and hospital, there is an observed difference in the representation of diseases at each level. The highest number of patients and services at the PHC level correspond to treatment of hypertension; in OSC it is back pain and osteoarthritis; and in hospitals, chronic coronary artery disease. Regarding the expenditure of the costliest ailments, at the OSC level these ailments relate to back pain, while again at the hospital level, it is chronic coronary artery disease. Figure 7: Share of patient and services relating to selected diseases (11) for Model 1 at the PHC, OSC and hospital level in 2015 60% 54.2 50% 40% 40.8 30% 24 20% 19 15.43 10% 11 0% PHC OSC Hospitals Share of patients Share of costs Source: World Bank own analysis based on NFZ data 19 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale Patients suffering from the one or more of the 11 selected diseases covered by the disease management (DM) scheme, account for 54.2% of all the patients at the PHC level, almost 41% of all OSC patients, and 15.5% of hospital patients. Around 24 % of all services provided at the primary health centers are performed in connection to the 11 diseases covered by the DMP management scheme. At the OSC level these services account for 18% of all services provided, in the hospitals the share is 11%. Figure 8: Costs of selected diseases (11) at the OSC and hospital level as a share of total costs of OSC and hospital care in 2015 18.00% 17.50 17.00 16.50 16.00 15.50 15.00 14.50 14.00 13.50 OSC Hospital Source: World Bank own analysis based on NFZ data Overall, the highest average number of patients and services across all three levels of care relate to hypertension at 7.1 million patients and 21.3 million services. When accounting for only OSC and hospital level care for the selected diseases under the model, the highest number of patients at 1.3 million and services at 2.8 million are associated with peripheral osteoarthrosis. Despite representing the highest number of services and patients, peripheral osteoarthritis is only the second most costly disease (1 billion PLN) among the selected diseases for Model 1, chronic coronary artery disease is first with a cost of 1.6 billion PLN. 20 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale Figure 9: Patients and services by selected diseases (11) at all three levels of care (PHC, OSC and hospital) in 2015 in Poland 8 mln 25 mln PLN 7 20 6 5 15 4 10 3 2 5 1 0 0 No. of patients Cost Parenchymal goiter and thyroid nodule Permanent atrial fibrillation Chronic heart failure Chronic Obstructive Pulmonary Disease (COPD) Asthma Hypothyroidism Chronic coronary artery disease Type 2 diabetes Peripheral osteoarthritis Back pain Primary hypertension Source: World Bank own analysis based on NFZ data Figure 10: Patients, services and costs of selected diseases at the OSC and hospital level in Poland in 2015 3.0 mln 1.8 bln PLN 1.6 2.5 1.4 2.0 1.2 1.0 1.5 0.8 1.0 0.6 0.4 0.5 0.2 0 0 No. of patients Costs Parenchymal goiter and thyroid nodule Chronic heart failure Permanent atrial fibrillation Chronic Obstructive Pulmonary Disease (COPD) Asthma Chronic coronary artery disease Type 2 diabetes Hypothyroidism Primary hypertension Back pain Peripheral osteoarthritis No. of services Source: World Bank own analysis based on NFZ data 21 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale Figure 11: Number of patients and costs related to selected diseases (11) in OSC and hospital care 2015 5.0 bln PLN 8 mln 4,730.03 mln 7.26 mln 7 4.0 6 5 3.0 4 2.0 3 2 1.0 993.46 mln 1 0.92 mln 0 0 Cost No. of patients OSC Hospital Source: World Bank own analysis based on NFZ data Despite the number of patients treated at the OSC level being more than 8 times higher than at the hospital level, the total cost of treating at the hospital level is almost 5 times higher than at the OSC level, only accounting for the selected diseases covered by the DMP scheme. Figure 12: Costs per 10,000 patients and 10,000 services at the OSC and hospital level in 2015 – selected diseases. Hospital 57,537,544 PLN 41,758,127 PLN OSC 1,369,314 PLN 611,099 PLN Patients Services Source: World Bank own analysis based on NFZ data 22 PILOT MODEL 1. IMPLEMENTATION MANUAL Rationale Figure 13: Costs of selected Outpatient Specialist Care consultations in relation to overall OSC costs Diabetology 2% Endocrinology 3% Cardiology 6% Neurology 5% Orthopedics 6% Pulmonology 2% Rehabilitation 1% Other 75% Source: World Bank own analysis based on NFZ data An important factor to consider is the large disparity in specialist care utilization and cost structures across regions (voivodships and powiats). In some cases, differences can be 20–60 times higher. Detailed analyses of the regional differences of the selected diseases (11) in the ambulatory care are available in Annex 1. 23 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model Scope The pilot provides patients with an extended package of health services at the primary health care level. The packages are designed to provide preventive and educational primary health care services to the whole population as well as to ensure comprehensive management for chronic diseases prevalent in the community. The first model of care – Model 1 provides the following changes to the scope of the health care services currently available at the primary health care level. Table 3: Scope of competencies of the current primary health care model (PHC) and Model 1 Scope of competency Current PHC Model 1 Medical certificates and reports Excessive No change Acute conditions Sufficient No change Children & adolescent health check-ups and immunization Sufficient No change Prevention and early diagnosis of chronic diseases Limited Extended Health and self-care education Limited Extended Diagnosis of CVDs, respiratory and skeletomuscular Limited Extended conditions Chronic disease management Limited Extended Outpatient diagnostic care Limited Extended Rehabilitation services in primary care None Available / limited Specialist consultations in primary care None Available / limited Diagnostic and treatment pathways None To be developed Personalized medical care plan None To be developed and implemented Service performance reporting Limited Extended Care quality monitoring None To be developed and implemented Patient engagement in care process Limited Extended Source: World Bank, 2017 24 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model Table 4: Scope of prevention of the current primary health care model (PHC) and Model 1 Type of prevention PHC Model 1 Children and adolescent health check-ups Sufficient Better reporting Children immunization Sufficient Better reporting Adult immunization (influenza, pneumococcus) Limited Extended Cardio Vascular Disease risks (CVD) Limited Extended Tuberculosis Limited Extended Smoking and COPD Limited Extended Pap smear Limited Extended Mammography and colonoscopy – recruitment at primary care None Available Early diagnosis of persistent Atrial Fibrillation (AF) None Available Adult health check-ups, 35–75+ years of age None Available Healthy life style education in risk groups None Available Education for patients suffering from chronic diseases None Available Source: World Bank, 2017 Table 5: Scope of diagnostics Type of disease PHC Model 1 Diagnostic tests Type 2 diabetes Limited Extended Microalbuminuria, C-peptide Hypertension Limited Extended Holter RR, echocardiography Persistent AF Very limited Extended Holter ECG, echocardiography Chronic CHD Very limited Extended Holter ECG, cardiac stress test Heart failure Very limited Extended Echocardiography, pro-BNP Thyroid gland diseases Limited Extended Anti-TPO antibodies and antithyroglobuline antibodies, thyroid fine needle aspiration biopsy*, thyroid scintigraphy* Bronchial asthma and COPD Limited Extended Spirometry/reversibility test Osteoarthritis of joints and spine Limited Extended CT*, MRI*, electroneurography*, rehabilitation in primary care * requested by the consulting specialist. Source: World Bank, 2017 25 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model The extended package of healthcare services is comprised of the following four elements: 1 the original/basic PHC package of services currently provided; 2 age and gender specific prevention and educational packages (0–18 years, adult females 19–64 years, adult males 19–64 years, 65+ years). Patients receive services under these packages according to their age and gender: this includes screening and preventive visits; 3 case management packages for the 11 most prevalent non-communicable diseases in Poland, this covers diagnostic tests and consultation visits and; 4 physiotherapy provided on an outpatient basis. A detailed list of the extended package is presented in Annex 3. 26 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model Model 1 implementation involves the following tasks. 1 Provision of medical care to patients covered under the contract. This includes prevention and education in health, based on organizational standards. This provision is encompassing of responsibilities of the family medicine team (physicians, nurses, PHC/community/family midwives, registration clerks, and – potentially – health educators, PHC/family medicine physician assistants, etc.), and the terms of their cooperation. 2 Identifying risk groups for chronic conditions in the population from Model 1 categories, and providing active counselling according to diagnosis and severity of the condition. 3 Developing, implementing, and coordinating of individual medical care plans for patients with chronic conditions from the Model 1 category, and creating diagnostic and therapeutic paths referred to in point III under the extended package. 4 Prescribing diagnostic tests included in Model 1 category in accordance with guidelines specified in diagnostic and therapeutic paths. Follow-up visits outlined in the care plan can be based on a referral issued by not only physicians, but other medical personnel. 5 Establishing means of communicating between care providers. Including the exchange of information about health events and medical records (EMC) supported by a robust IT system (possible transition period from reliance on hard copy records). All relevant patients’ health information should be made available at the first encounter to the PHC/family physician, who acts as the coordinator of care and the guides the patient through the system. 6 Monitoring and supervision of service quality and efficiency. 27 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model Table 6: Key organizational features of Model 1 Mandatory Recommended Organizational regulations N/A Delivery of disease prevention programs, Hiring qualified non-clinicians including adult and child well-care appointments with record of performed examinations Enrollment to population screening examination Collecting samples for population-based program of early detection of in relevant area e.g. cervical cancer, breast cervical cancer cancer, colorectal cancer Stratification of patients suffering from chronic Stratification of patients suffering from other long-term conditions; diseases managed in Model 1 setting (based commitment of qualified non-clinicians on quantity and type of chronic diseases, advancement stage and degree of self-reliance); IPOM (Individual Medical Care Plan) based on IPOM (Individual Medical Care Plan) recorded in the IT system DTP (Diagnostic and Therapeutic Path) Coordinated healthcare appointments planned Coordinated healthcare, planning visits, monitoring of patient’s adherence, by PHC staff performed by sub-contractor (e.g. Contact center) Results of diagnostic check-up and consultations Diagnostic check-up results are commissioned and collected via IT system with specialized physician are collected by PHC control tests determined in IPOM (Individual Medical Care Plan) may be Model 1 facility directly from the subcontractor ordered by non-clinicians (no patient involvement) Educating patients how to handle long-term Having non-clinicians involved in performing those tasks disease and healthy lifestyle managed in Model 1 setting Monitoring of performance of medical Assistance in monitoring adherence, including consumption of prescription recommendations by primary care physician medication by non-clinicians or sub-contractor (e.g. Contact center), and if personal data protection requirements are met Organized physical therapy for PHC patients Physiotherapy studio provided on PHC clinic premises. Registration to physical therapist treatment, waiting time depends on medical recommendations described in the Diagnostic and Therapeutic Pathways (DTP) Internal and external monitoring and oversight Internal and external monitoring and oversight of services in recommended of mandatory services scope. Maximum involvement of non-clinicians Source: World Bank, 2017 Regarding patients who have an elevated health risk or have been diagnosed with a chronic condition from Model 1 category, procedures are established for monitoring their health status e.g. active counselling. Ultimately, each eligible patient diagnosed with a chronic condition included in the list ought to participate in educational programs dedicated to his/her condition management, with the use of educational aids including e-learning tools. Coordination of care over patients with syndrome complexes and selected chronic conditions under Model 1 28 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model Model 1 services concern diagnostic and therapeutic procedures relevant for patients with syndrome complexes and chronic conditions from the Model 1 selected diseases, at present these patients are typically referred to OSC clinics. These services can be performed by a PHC/family physician authorized to accept patient declarations or by another physician who cooperates with the above-mentioned PHC/family physician and has appropriate competencies e.g. a family medicine, general medicine or internal medicine specialist who has a long tenure in PHC. When a patient is diagnosed with a chronic condition from the Model 1 selected disease category, the physician, along with patient’s involvement and agreement, develops a medical care plan e.g. active counselling plan, in line with diagnostic and therapeutic paths (developed by the NFZ), and orders necessary tests and specialist consultations. The PHC/family physician team coordinates the medical care plan. On consulting with the patient, the physician decides on a treatment plan and supervises the implementation of the plan. Collaborating service providers or subcontractors e.g. the contact center (provided that a relevant confidentiality agreement regarding the patient’s health data is submitted), schedules the visits prescribed by the medical care plan. Personnel, other than physicians e.g. a PHC nurse, can also monitor compliance with the recommendations. Outpatient rehabilitation The scope and maximum waiting time for physiotherapy services is more closely linked to medical indicators prescribed in diagnostic and therapeutic paths than those observed in the existing system. Rehabilitation and physiotherapy services are among the most requested health areas by patients using specialist care facilities. Lower back pain, neck pain and middle back pain are on the list of six main self-reported health issues (2). The demand for physiotherapy and rehabilitation makes it an important area included in the PHC enhanced scope of service. At the same time, with a limited budget, lack of clinical/ therapeutic path for treatment, and high demand, the issue of overspending requires mitigation whilst also assuring good quality of services. As a result, a pay-for-performance based solution is proposed with a maximum ceiling for selected services. The scope and maximum waiting time for physiotherapy services is linked to need and treatment plan and the proposed solution is outlined but not obligatory. 29 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model Prevention The pilot facilities will lead an active role in education, prevention and prophylaxis. These activities will be supported financially and organizationally. Given that the planned actions can impact individuals without symptoms, they should be put in place for each proposed action that does not pose a threat to safety, does not create health inequalities, and is effective with respect to the expected costs and identification of obstacles to their implementation. Tools are adapted to the different levels of prophylaxis: ■■ Early prophylaxis – variation of normal patterns of healthy lifestyles and prevention of the spread of negative patterns of behavior in relation to healthy people. Tools used in the framework of early prophylaxis include: overall assessment of the health, health education, support health-promoting activities. ■■ Primary prevention – preventing the disease by controlling risk factors in respect of persons exposed to risk factors. Tools used in primary prevention include: an overall assessment of the state of health, health education, support health-related activities within the identified risk factors. ■■ Secondary prevention – prevention of the consequences of the disease by the early detection and treatment, for example screening tests to detect illnesses. Tools used in secondary prevention include: screening of the general population PHC. ■■ Tertiary prevention – stopping the progress of the disease and reduce complications. Tools used in the framework of tertiary prevention include: a treatment plan determined between the patient and the PHC doctor. 30 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model One of the constant elements for carrying out prevention and prophylaxis is child health check-ups, in line with the existing scheme. In order to create robust reporting systems, it is proposed to record data more comprehensively from the child health check-ups in the IT system, which allows analyses and operations using these data. The second key element of prevention and prophylaxis is adult check-ups. The extensiveness of check-up tests and further intervention depends on age and risk factors. The following Pro-Health activities are covered for all patients in the Model 1: 1 prevention and education activities (including assessment of general health status and in-depth interviews); 2 screening actions (screenings of proven effectiveness) and; 3 further care based on the health conditions and on the preventive and prophylaxis actions that are undertaken. Care may involve the designation of further prophylaxis steps as well as creation of the health and treatment plan if diseases are detected during screening. Preventive activities concern the identification of risk factors in the general population through in-depth interviews, general assessment of health, and screenings. Prophylaxis activities (including screenings) are indicated in the study based on scientific guidelines of the main risk factors and lifestyle diseases. These apply to different age groups, from 0 to 65+ for the following health issues, risk factors or diseases: ■■ Tobacco use ■■ Overweight / eating disorder ■■ Alcohol abuse ■■ Low physical activity ■■ High blood pressure ■■ Elevated levels of cholesterol and other lipids 31 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model ■■ Excessive consumption of salt ■■ Family history ■■ Diabetes ■■ Cardiovascular disease ■■ Chronic lung disease ■■ Depression, dementia ■■ Seeing, hearing ■■ Vertigo ■■ Oncological diseases ■■ Anemia ■■ TB ■■ Osteoporosis ■■ Poor posture Table 7: Interventions in the assessment of the patient’s general health Overall health rating: basic research laboratory Funded within the capitation PHC (NFZ funds) – glucose, serum, or urine Screening cytology, mammography colonoscopy Research funded separately (FFS) (EU funds) / occult blood In-depth nurses interviews, a preliminary Advice separately funded FFS (EU funds) assessment of health, measuring BMI, health education An in-depth medical interview (by doctor), overall Advice separately funded FFS (EU funds) health assessment, further treatment / path proceedings, health referral to educational visit Prophylaxis interventions, strengthening tobacco Funding under the grant awarded for preventive interventions. Grant to be control intervention, psychological support, determined and awarded on the basis of individual proposals POZ team. purchase products to help stop smoking, The purpose of the grant is to provide support tools for implementing exercise with a trainer, nutritionist, etc. the activities screening, prevention and education. (EU funds) The detailed list of screening tests and possible interventions to be conducted under Model 1 could be found in Annex 2 Source: World Bank, 2017 32 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model Transfer of Tasks to PHC Nurses and Health Educators Personnel, other than physicians, to be engaged as much as possible in the following tasks: ■■ implementation of prevention programs; ■■ health education, and; ■■ follow-up visits and education of patients with chronic conditions from the Model 1 selected diseases. Patients/Enrollees Model 1 is designed as an extended package of healthcare services for 250,000 to 500,000 patients throughout the country. The final number of patients depends on the number of contracts signed by the NFZ. Patients are automatically enrolled in the pilot once their provider participates unless the patient opts out: patient participation in the pilot is voluntary. Patients continue to have the option to change providers three times a year without incurring a charge. Patient resignation from Model 1 services The Model 1 covers all patients enrolled with the PHC/family physician through patient declarations. The patient has the right to de-enroll from this model of care and to choose to be treated for one of the Model 1 chronic conditions by an outpatient service clinical physician. In the case of de-enrollment, the patient should communicate his/her intention to opt-out in writing, which the recipient faculty is required to record in the patient’s medical history and in the Model 1 IT system provided by the NFZ. The patient who de-enrolls once from the services within the integrated care can change their mind and enroll again to proposed model of delivering services once a year. Funding for the patient who resigned from Model 1 services is adjusted accordingly in the period determined with NFZ. The facility holding a Model 1 contract is required to provide the contracted patients with the full scope of PHC services as appropriate. 33 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model Providers The extended package of healthcare services is provided to patients through contracted providers. Between 50 and 150 providers are involved in this pilot. To ensure that the sample of providers adequately represent the providers in Poland, the sample is determined using the criteria presented in Table 8. Table 8: Selection criteria for the sample providers Criteria Options Options Options Remarks Region Urban Rural All regions recommended for inclusion Type of practice Primary care doctor Primary care doctor All kinds of practices + family practice nurse + family practice nurse recommended for + midwife inclusion Size of population per Large (>10,000) Medium (2,500–10,000) Small (<2,500) All sizes recommended practice for inclusion Ownership Private Public All kinds of ownership recommended for inclusion Source: World Bank, 2017 When finalizing the total number of facilities participating in the pilot, it is recommended that the appropriate economies of scale are reached i.e. the number of facilities participating in the pilot should not be lower than 50. Correspondingly, the number of facilities should not exceed 200 for the first model to allow comprehensive implementation of the pilot. For planning purposes, the number of facilities predicted in the cost calculation sheet is 75. Rationale for Sample Criteria Region In Poland, the most populated provinces are Mazovian (13.9%) and Silesian (11.9%), while the least populated regions are Opole (2.6%) and Lubuskie (2.7%). (3) However, on average, most beneficiaries per single provider occurs in the Mazovian (6,735), Łódzkie (5,090) and Kujawsko–Pomorskie (5,073), and the least in Western Pomerania (1,617). (4) The patient per doctor ratio is 2,250:1 in Lubuskie, while the largest is 4,588:1 in Pomerania. Despite this, there is no regional variation in terms of access to medical advice for the sick, or difference between the availability for sick men or women. (5) To better 34 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model understand the characteristics that impact quality of care, the sample includes facilities of different sizes, patient types and patient doctor ratios. Table 9: Availability of medical advice in the WOBACZ study Facility Women % Men % Small community 97.3 96.7 Medium community 96.5 96.5 Large Community 96.6 93.3 Voivodship Cities 98.0 96.9 Total 97.0 96.6 Source: Piotrkowski and Polakowska (2010) Type of practice (4) In 2015, there were over 6,000 Primary Care agreements with the National Health Fund, contracting a total of 32,292 doctors: 80% employed in corporations and 1% working in group or individual practices. Three types of practice contracts are used for the provision of health care services at the primary care level: primary care doctor’s contracts, family nurse contracts, and midwife contracts. The average share of doctor’s services as contracting agreements in Poland is 49%. These agreements are most common in central Poland in Mazowieckie, Lodzkie and Kujawsko–Pomorskie, where patients using services under a contracted agreement exceeds 75%. The lowest utilization of contracts is in the Wielkopolska Region at 10% share; this region is dominated by contracts with individual practices, along with the Opolskie province (15%), Podkarpacie (22%) and Lubuskie (24%). Within the integrated care pilot, to include facilities where all three agreements are present is optimal: meaning that primary care doctors, family practice nurses, and midwives are all together. There is no requirement to have individual agreements between the three medical practitioners and the NFZ, even with individual practices a doctor can have an independent agreement or set up a joint agreement with a family nurse and/or midwife to treat an individual patient. Size of the population The population density is greatest in the areas surrounding the main medical administrative centers, and correspondingly these centers process the largest amounts of contracts. The number of patients per doctor varies considerably depending on the organizational and legal structure. The highest number of patients per provider is in Mazovia, this is because of the proportion of larger facilities in this region to cater to the large population, although there is more staff employed, the patient to practitioner ratio is still higher than, for example, in Lubuskie. Independent practices are operating mainly in smaller towns (4) and the National Health Fund recommend a ratio of 2,750 patients per family doctor. In regions where there is a smaller number of facilities and a smaller 35 PILOT MODEL 1. IMPLEMENTATION MANUAL Service delivery organization model population, there is a higher number of patients treated by group practices. To determine the size of the practice that should be included in the pilot, practices were divided into Small (around 2,500 patients per 1 doctor), Medium (2,500–10,000 patients per 1 doctor) and Large (more than 10,000 patients per 1 doctor). However, to determine if the size of the population impacts the program and what kind of practice, individual or group, would be the most effective in a coordinated care pilot, all populations should be included. Type of ownership In 2015, the National Health Fund had agreements with 6,226 providers, 83.3% of whom are self-employed. Most of these types of agreements are made in the province Silesia, Mazovia, Wielkopolska, the least were made in the province of Świętokrzyskie. (4) All types of ownerships should be represented in the pilot to create an encompassing scenario of the provider dynamics and to represent free market laws. ■■ Provider participation is voluntary and governed by legal agreements between the NFZ and the provider. Contracted providers are responsible for providing patients with preventive, primary services and case management of non-communicable diseases, as determined by the 11 selected diseases covered in the Model 1 extended package. ■■ Testing that requires additional capabilities and advanced technology is referred to pre-selected subcontracted institutions in their catchment area. As such, providers play a gate-keeping role referring patients to appropriate facilities for diagnostic procedures and to specialists. ■■ Providers are responsible for contracting with specialists and diagnostic services not available in their facility to ensure that the full range of services included in the new package are available to the patient. ■■ Quality of Providers Care under this pilot is the responsibility of the NFZ and is monitored and maintained through the M&E system with the use of indicators determined in the capital on Monitoring and evaluation. 36 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Currently, all PHC providers in a defined geographic or administrative area are reimbursed at the same per capita rate: that is, the base per capita rate. Under the pilot, a revised capitation rate was calculated to account for the cost of additional services under Model 1. Additional services are aggregated into six clinical areas including diabetes, endocrinology, cardiology, neurology, pulmonology and orthopedics. This new per capita rate is used to determine the provider’s budget. Two ways of determining a providers’ budget under Model 1: ■■ base per capita payment plus an additional percent increase to accommodate for specialist services, or; ■■ base per capita payment adjusted for the different population groups. Risk adjustment is used to correct the rate for creating incentives and compensating providers for serving populations with different health needs. In the Model 1, providers are compensated for prevention, management of chronic diseases, and providing more diagnostic tests for population groups with different health needs. To calculate the PHC per capita payment system, several factors are considered: the current NFZ base per capita rate; population size, characteristics, and enrollment with providers; and adjustment coefficients. Risk adjustment coefficients for each of the six aggregated clinical areas are calculated. NFZ 2015 expenditures for the six categories are used as a proxy for the cost of services. Historical costs are assumed to be kept constant for the duration of the pilot. Main assumptions of funding for model 1 The pilot project is implemented in a specific number of voivodships. The final number of voivodships depends on the finalization of the number of PHC patients covered by the pilot project, as well as the institutions recruitment. However, it is recommended that the pilot project takes place in all 16 voivodships. The core personnel in the pilot are PHC doctors whose number depends on recruitment results. For budget estimation, it is assumed that 150 doctors participate. At the early stage of the pilot project, several medical specialty personnel are identified who are expected to support PHC doctors in conducting schemes of managing patients with the selected chronic diseases. As part of this mode of care, it is assumed that a Model 1 doctor cooperates with practices of doctors of the specialties listed (6 specialties of OSC), and not necessarily just with legal entities specified in the Act on Health Care Services. This means that the above- 37 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing mentioned specialists may perform services at institutions that do not have independent contracts with NFZ, or any Model 1 institution, as well as through tele-medical means. Apart from PHC doctors, the participants of the pilot project are also doctors within the six selected specialties. The overall number of doctors within these specialties depends on the number of institutions involved in the Model 1 pilot project, but is estimated at 192 specialists. Gradually during the pilot project and once it is finished, it is planned to incorporate further therapy areas and consultants within other specialties. The final number relies on the capacity to comprehensively provide care to the patient population. To plan the pilot accordingly, an assumption of the population in the care of each PHC doctor is made, this assumption does not deviate significantly from the existing average population per PHC doctor figure. It is assumed that 2,000 patients are in the care of one doctor. Over time, as obligations and revenues from providing services to the population of patients increase, the overall number of patients per doctor is expected to decrease. The pilot project is intended to address smaller institutions, often located in small towns, but there are no formal restrictions in place. For the purposes of the model, an average number of two PHC doctors/administrators of the patient list per institution, where the total number of institutions is 75. The total number of PHC patients participating in the pilot project is estimated at several hundred thousand. The final number is to be finalized after the recruitment stage and at the stage of submitting applications for the second stage of the project. Flexibility is required regarding the assumed number of patients at pilot project institutions, the final number partially depends on the population structure of the pilot project patients. It should not be assumed that the number of patients at institutions involved in the pilot project reduce with its implementation. It is estimated that the population covered by Model 1 is 300,000 people. Figure 14 presents the proportion of the total budget as represented by the Model 1 pilot project, divided into expenditure categories. Figure 14: Cost of the Model 1 pilot project as % of NFZ (National Health Fund) budget – divided into categories 0.14% 0.12% Management 0.10% DM 0.08% Rehabilitation 0.06% Prophylaxis and prevention 0.04% PHC capitation 0.02% 0.00% 2018 2019 2020 2021 Source: NFZ, 2016 38 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing The basic activity of the pilot project institutions is within the current scope of PHC competencies, whereas the remuneration and current capitation rates , i.e. PLN 144 per person, are adjusted using the current correction coefficients. In the model, a per capita payment system based on the analysis of the costs of the new extended package of Model 1 are used. Currently, all the PHC service providers are remunerated according to the same per capita rate, which is a basic rate adjusted according to various criteria. The base rate is per capita, plus an additional percentage subsidy related to specialized services. For the pilot program, a revised per capita rate is determined which accounts for the additional costs of services provided as part of Model 1, and reinforces the institutional changes at the level of the service provider. Additional services are included in disease management in six clinical areas: diabetes, endocrinology, cardiology, neurology, pulmonary diseases and orthopedics. In Model 1, service providers are remunerated for prophylactic activities related to chronic diseases and for conducting a specific number of diagnostic tests for groups of people with various health needs. Costing of the package – sources of funding The new capitation rate factors in the following costs of care: ■■ In relation to all registered patients, without exceptions: – “administrative” expenses, including: the coordination of educational and prophylactic activities, new organization of the family medicine team’s work, contracts and coordination with specialists, and internal supervision and monitoring of the quality of care and; – “technological” expenses, including: computer equipment, equipment necessary for tele-consultation and remote monitoring of health parameters, and IT systems and software. ■■ In relation to patients with chronic diseases under Model 1, the rate factors, without exceptions: – coordination expenses, and; – expenses related to additional follow-up visits and tests. The per capita rate of Model 1 for all patients registered with PHC constitutes the sum of the PHC rate and the cumulative PHC rate related to the above- mentioned expenses for patients in each age group. 39 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Figure 15: The division of the four-year pilot project costs according to the type of services funded as part of the new capitation Rehabilitation 8.91% Prophylaxis and prevention 4.78% PHC capitation 86.31% Source: World Bank, 2017 In the case of patients with chronic diseases under the categories of Model 1, there is an additional per capita rate factoring the cost of care related to disease management. The cost of services in the pay-for-performance model and fee-for-service model calculations are based on historical data from NFZ and market estimates in the case of services for which the necessary data is not available. Prevention and prophylaxis The pilot project institutions adopt a proactive approach in the areas of education, prevention and prophylaxis. These measures are supported in terms of funding and organizational structure. One of the permanent elements of prevention and prophylaxis are child health reviews. To reinforce and implement good reporting practices, it is recommended that data from child health reviews is registered more extensively. The registration of data from child health reviews are remunerated at a fixed amount of PLN 5 per data entry. It is assumed that coverage of the child population for health reviews is 95%, and remains constant throughout the pilot project period. Another permanent element of prevention and prophylaxis are the “so-called” adult health reviews. The scope of review examinations depends on the patient age group, this scope also influences the cost. The costs of review examinations 40 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing are to be covered by EU funds and are preliminarily estimated based on the analysis of existing review costs: an average of PLN 200 per review. It is assumed that the coverage of the adult population for health reviews increases annually during the pilot project period at a rate of 5%, the starting point of coverage level by health reviews in the first year of the pilot project differs depending on age: by 5 year intervals ranging between 35–39 up to and inclusive of 65–69 years of age. In the first year of the pilot project, the population coverage is estimated at 35%, and in the last year at 60%. Disease management program (DMP) The pilot project institutions launch a care scheme referred to as “disease management” for the selected chronic diseases. In the initial period, the list of 11 selected diseases is not expanded. The 11 conditions and their corresponding proportion of affected population are presented below: ■■ Type 2 diabetes: 7.4% ■■ Hypothyroidism: 3.4% ■■ Parenchymatous and multinodular goiters: 2% ■■ Essential hypertension: 22.9% ■■ Chronic coronary disease: 4.3% ■■ Chronic heart failure: 1.7% ■■ Chronic atrial fibrillation: 0.9% ■■ COPD: 5.7% ■■ Asthma: 8.6% ■■ Osteoarthritis of the peripheral joints: 15% ■■ Spinal pain syndromes: 20% This list may expand over time by new conditions for adults and an unknown number of chronic diseases affecting children. The population estimates of patients affected by the above-mentioned diseases does not translate into the number of people treated for these conditions, as shown in Table 10. 41 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Table 10: Epidemiological data on 11 DMP diseases Diseases covered Epidemiological Studies (e.g. GUS, Data from Number of people treated – NFZ by DMP data NATPOL, WOBASZ, clinics – valuation SHARe etc.) Essential hypertension 22.9% 38% of women, 44% 8.8%, 13%, PHC – 15.99% SOC – 2.34% of men, 32%, 3 million 19%, 21%, underestimated 28%*, 21.5%, Hosp. – 0.17% Therap. rehab. – 0.01% 14.1% Type 2 diabetes 7.4% 9.8%, 12.8%, annual 1.4%, 2%, PHC – 3.65% SOC – 2.17% increase in the 2.2%, 5.6%, number of patients 1.8% 7.4%, Hosp. – 0.19 Therap. rehab. – 2.5% 7%** – 0.003% Chronic coronary 4.3% 9% 0.6%, 0.9%, PHC – 2.62% SOC – 1.77% disease 1%, 3.7%, 1.3% Hosp. – 0.46% Therap. rehab. – 0.019% Chronic atrial 0.9% Diagnosable 1–2%, 0.8%, 1.2%, PHC – 1.02% SOC – 0.58% fibrillation concerns 3–5% 2%, 2.2%, 2.2%, 1.9% Hosp. – 0.19% Therap. rehab. – 0.0004% Chronic heart failure 1.7% 2.1–2.6 (diagnosed 0.6%, 0.9%, PHC – 1.19% SOC – 0.28% in 53% of people 1%, 1.7%, over 65) 2.4%, 0.4% Hosp. – 0.4% Therap. rehab. – 0.02% Asthma 8.6% 4.1–4.6%, symptoms 0.7%, 1%, 2%, PHC – 1.8% SOC – 1.96% present in 13% 1.8%, 1.9% Hosp. – 0.1% Therap. rehab. – 0.01% COPD 5.7% 5.2 %, 1.4% treated 0.2%, 0.4%, PHC – 0.96% SOC – 0.82% for this reason 1%, 0.7%, 0.7% Hosp. 0.10% Therap. rehab. – 0.012% Parenchymatous 2.0% — 0.1%, 0.2%, PHC – 0.24% SOC – 0.27% and multinodular 1%, 0.5%, goitres 0.1% Hosp. – 0.02% Therap. rehab. – 0.00008% Hypothyroidism 3.4% 1–6%, 3.8 – thyroid 0.7%, 1%, PHC – 1.94% SOC – 2.44% diseases in general 4%, 1.5%, 2.9% Hosp. – 0.06% Therap. rehab. – 0.0008% Osteoarthritis of the 15.0% 15% 1.5%, 2.3%, PHC – 3.69% SOC – 3.1% peripheral joints 9%, 8.5%, 1.6% Hosp. – 0.25% Therap. rehab. – 2.18% Spinal pain syndromes 20.0% 22–57%, 7.1%, 10.8%, PHC – 6.11% SOC – 3.14% 2%, 8.9%***, 18.3%, 6.5% * with secondary hypertension I15 ** with type 1 diabetes E10 (% of cases among patients declared, not visits) *** only M47 – spondylosis Source: WB 2016, based on the data provided by PHC service provider 42 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing To estimate the costs of treatment for the above diseases, data on the utilization of services funded by the NFZ and additionally, the percentage of the population treated in the public system for the above-mentioned diseases are considered. The results indicate that for certain diseases/conditions a considerable percentage of individuals do not seek treatment. Some case examples are illustrated in Table 10. This under-treatment leaves substantial room for increase in the number of diagnosed cases, and consequently, in the number of patients to potentially incorporate into DMP schemes. This possible outcome is factored when estimating the numbers of people covered by DMP schemes. Figure 16 indicates the breakdown and allocation of funds under the Model 1 pilot project, a distinction is made between DMP care received through PHC or specialist care. Figure 16: Division of pilot project funds of total Management – PHC (12%) DM – specialists (8%) Rehabilitation – specialists (6%) Prophylaxis and prevention – specialists (2%) Capitation – PHC (59%) DM – PHC (11%) Prophylaxis and prevention – PHC (2%) Source: World Bank, 2017 Estimated percentage of people suffering from the following illnesses who receive care services relating to the illness: ■■ Type 2 diabetes: 80% ■■ Hypothyroidism: 80% ■■ Parenchymatous and multinodular goiters: 95% ■■ Essential hypertension: 80% ■■ Chronic coronary disease: 95% ■■ Chronic heart failure: 95% ■■ Chronic atrial fibrillation: 95% ■■ COPD: 50% 43 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing ■■ Asthma: 60% ■■ Osteoarthritis of the peripheral joints: 40% ■■ Spinal pain syndromes: 40% On implementing disease management (DMP) schemes, the pilot participating institutions are provided with additional funds, available in the form of allowances calculated per person covered by DM, with the option to settle some services in the fee-for-service (FFS) mode. Allowance in addition to PHC capitation   Only partial take-up by patients with chronic diseases of the DMP scheme is assumed. However, a parallel assumption is made that sees a slow and gradual increase in the percentage of people officially covered by this type of care. In subsequent years of the pilot project, the following percentages of patients covered by DMP schemes are assumed: ■■ 2017: 35% of the population of a given service provider ■■ 2018: 40% of the population of a given service provider ■■ 2019: 45% of the population of a given service provider ■■ 2020: 50% of the population of a given service provider The additional allowance is provided with the intention of subsidizing the more intensive care services offered to persons who qualify for DMP schemes that basic capitation does not cover e.g. medical advice, PHC diagnostic tests, nursing care. This intensive care is provided by specialist doctors, but is now being provided at PHC. The suggested amounts reflect the proportion of costs incurred for patients with these diseases in Specialist Outpatient Care (approx. half of the expenditure per person in SOC for a given disease). The allowance is calculated for the period the patient is covered by the DMP scheme i.e. from the date on which the patient is reported as a person covered by the scheme until the date he/she uses services within a given specialty outside the institution’s cooperative network. The amounts of the annual capitation allowance for DMP scheme coverage for each condition are presented below: ■■ Type 2 diabetes: PLN 60 ■■ Hypothyroidism: PLN 50 ■■ Parenchymatous and multinodular goiters: PLN 80 ■■ Essential hypertension: 60 PLN ■■ Chronic coronary disease: PLN 60 ■■ Chronic heart failure: PLN 60 ■■ Chronic atrial fibrillation: 60 PLN 44 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing ■■ COPD: PLN 50 ■■ Asthma: 50 PLN ■■ Osteoarthritis of the peripheral joints: PLN 40 ■■ Spinal pain syndromes: PLN 40. DMP consultations  Aside from the DMP allowance and capitation amount, an institution has the opportunity to charge for selected types of consultations provided to patients covered by DMP schemes. This advice is provided as frequently as is recommended by the Disease and Therapeutic Pathways (DTP) and the individual patient’s needs. As part of the pilot project, the possibility to provide this consultation depends on substantive review (based on the DTP). In the case of multi-morbidity, it is assumed that comprehensive and educational consultations cover all conditions affecting a given patient. As part of the pilot project, an expected outcome is establishing an optimum frequency of consultations, including other activities not covered by the fee- for-service (FFS) method. The types of consultations with the suggested rate are presented below. The rates have been specified based on market rates, historical trends, and expert advice. ■■ Comprehensive medical advice: PLN 80 ■■ Specialized consultation: doctor-patient: PLN 80 ■■ Specialized consultation: doctor-doctor, including tele-consultation: PLN 50 ■■ Educational advice (coping with the disease, diet, etc.): PLN 30.   DMP diagnostics To improve service to patients covered by DMP schemes, it is possible to provide diagnostic tests and activities from the list of DMP diagnostic tests. At present, these tests are conducted and charged as part of OSC and OCDS (outpatient cost-intensive diagnostic services), whereas in the pilot project, they are provided at the order of a PHC doctor. The list of tests and amounts are presented below. The rates have been specified based on market rates, historical trends, and expert advice: ■■ Spirometry and reversibility testing: PLN 50 ■■ Cardiac stress test: PLN 100 ■■ Thyroid fine-needle aspiration biopsy, guided: PLN 210  ■■ Laboratory diagnostics: – Microalbuminuria: PLN 30  – C-peptide: PLN 40  – B-type natriuretic peptide (BNP, nt-proBNP): PLN 100  – thyroid peroxidase antibodies: PLN 35 – thyroglobulin antibodies: PLN 35 ■■ Echocardiography: PLN 120 45 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing ■■ ECG Holter monitoring: PLN 130 ■■ BP Holter monitoring: PLN 90 ■■ Examination of the fundus oculi: PLN 60 ■■ Geriatric tele-consultation: PLN 69. The set of examinations currently performed as part of OSC are based on the number of reported tests and test price proposed for the purposes of the pilot project. Although there is an assumed increase in individuals covered by the DMP scheme, the optimum value for frequency of treatment in clinical practices is established only during the pilot. Thus, the amount of expected expenditure is predicted. Rehabilitation The pilot project institutions can avail of funds to be used for specific rehabilitation services. Although initially, the specified scope of care only covers rehabilitation in spinal pain syndromes and osteoarthritis of the peripheral joints. The organization and coordination of rehabilitation services is the responsibility of pilot project institutions. The maximum budget for acquiring these services is fixed and calculated based on the current level of use of physiotherapy services by age groups, as below: ■■ 0–9 years: 0.33% ■■ 10–19 years: 0.60%  ■■ 20–29 years: 1.43% ■■ 30–39 years: 3.92%  ■■ 40–49 years: 9.14% ■■ 50–59 years: 17.22% ■■ 60–69 years: 22.61% ■■ 70–79 years: 24.80% ■■ 80–89 years: 11.54%  ■■ 90+ years: 2.00%  The budget is calculated considering the average rehabilitation cost at physiotherapy facilities in 2015, which amounted to PLN 216 per person.  Due to limited access to rehabilitation services, especially for the 11 selected conditions, the size of the budget available for the facilities patients is increased by one and a half times, assuming a proportionate increase in the number of people obtaining access to those services. 46 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Technological and administrative allowance   For the PHC institutions participating in the pilot project, it is obligatory to implement or expand and use IT systems to record data and to exchange electronic information with other institutions and with the payer. It is necessary to carry out investment to transition to these enhanced IT systems (an assumption is that basic IT infrastructure already exists). The development of IT systems, including tele-consultation desks, is compensated with a technological allowance of PLN 50,000 paid out incrementally throughout the pilot period. The value of the technological allowance is anchored to market prices of hardware and software per doctor and supporting personnel (nurse, receptionist, coordinator) work stations. The value of the allowance for a given institution depends on the number of PHC patients (2,000 on average). The allowance is paid in quarters over a four-year period. Doctors of other specialties participating in the pilot project also receive a technological allowance, calculated similarly to the PHC technological allowance: based on the number of patients of a PHC doctor who is a partner of a specialty doctor. The purpose of this allowance is to enable the introduction of tele-medical consultation opportunities as well as the exchange of electronic medical documentation. The amount of the technological allowance provided for a period of four years is PLN 10,000. Institutions participating in the pilot project must carry out some additional administrative and coordination functions, especially related to recruitment for prophylactic tests, organizing services for patients in DM programs, etc. To cover some of these measures, the institutions receive funds calculated per person in care, estimating the necessity to employ one person per approx. 2,000 patients. The predicted total monthly cost incurred by the employer is PLN 5,000. Management and development of the payers’ competencies The payer, who is a beneficiary of the project, conducts activities related to project management as part of the project implementation unit (PIU), and develops competencies in terms of acquiring, controlling and managing care in the system of coordinated health care. Employing committed individuals aids the development of the beneficiary’s competencies, before the employed individuals then become core elements of the payer’s structure in the future. The payer develops the model of coordinated care on a national level, and is equipped with new IT tools for serving the pilot project as well as new functions not implemented at present e.g. documentation exchange, recording medical data. This report does not contain an estimation of the costs of managing and administering pilot projects as the beneficiary’s project costs. 47 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Diagram 1: Financing model for Model 1 PHC PHC + (education PHC Capitation Rehabilitation Disease management & prevention) Chronically ill patients (epidemiological data) Entire population (persons covered by pilot) Capitation Consultations Diagnostics Assumptions concerning planned coverage of the population (growing in the planning period) 200% 10% 20% 40% 100% 5% 10% 20% 0% 0% 0% 0% 2017|2018|2019|2020 2017|2018|2019|2020 2017|2018|2019|2020 2017 | 2018 | 2019 | 2020 Annual cost per “examination/patient” (constant during the planning period) Cost of prophylaxis Cost of Cost of capitation Cost of disease management and prevention rehabilitation 100% 52% 48% 100% 59% 41% PHC (82%) Specialized care (18%) Financing NFZ European Union Funds Ongoing cost of capitation Certain examinations Management by NFZ Administration of PHC 48 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Costs of the pilot programme: summary The total cost of the pilot is finalized after agreement by the NFZ on the scale of the pilot and detailed health service cost calculations are established. Table 11: Summary of costs (in PLN) 2020 2019 2018 2017 Name Entire period PHC capitation 238.930.964 59.732.741 59.732.741 59.732.741 59.732.741 Prophylaxis and prevention 13.220.678 2.881.592 3.163.977 3.446.362 3.728.747 Rehabilitation 24.675.440 6.168.860 6.168.860 6.168.860 6.168.860 DMP – total 77.527.521 15.961.548 18.241.770 20.521.991 22.802.212 DMP – capitation 15.777.700 32.486.350 3712400 4.176.450 4.640.500 DMP – advice 44.416.208 9.144.513 10.450.872 11.757.231 13.063.590 DMP – diagnostics 17.333.614 3.568.685 4.078.497 4.588.310 5.098.122 ADMINISTRATION – TOTAL IT system – total 14.420.000 7.355.000 2.355.000 2.355.000 2.355.000 IT system for institutions – PHC doctor 7.500.000 1.875.000 1.875.000 1.875.000 1.875.000 IT system for institutions – doctor of another 1.920.000 480.000 480.000 480.000 480.000 specialty, PHC partner IT system for NFZ 5.000.000 5.000.000 0 0 0 Other administrative functions 14.400.000 3.600.000 3.600.000 3.600.000 3.600.000 Pilot project supervision 12.336.000 3.084.000 3.084.000 3.084.000 3.084.000 Building payer’s potential 7.104.000 1.776.000 1.776.000 1.776.000 1.776.000 Total 402.614.604 100.599.741 98.122.348 100.684.954 103.247.561 EU contribution 78.814.292 Increase in the revenue of institutions 58% 52% 56% 60% 65% Source: based on Annex 3 49 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Figure 17: Resource allocation in the pilot Management – PHC (12%) DM – OSC (8%) Rehabilitation – OSC (6%) Capitation – PHC (59%) Prophylaxis and prevention – OSC (2%) DM – PHC (11%) Prophylaxis and prevention – PHC (2%) Source: World Bank, 2017 Figure 18: Annual pilot budget – First year 120 mln PLN 100 DM – OSC 80 Rehabilitation – OSC Prophylaxis and prevention – OSC 60 DM – PHC Prophylaxis and prevention – PHC 40 Capitation – PHC 20 Management – PHC 0 Source: World Bank, 2017 Hypothetically, If the model assumptions are applied to the entire country, the total NFZ expenditures for Primary health care would need to increase by 10 billion PLN over 4 years as per Figure 19. 50 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Figure 19: Estimation – Model 1 pilot, whole country integrated care vs. NFZ expenditures 2018 2019 bln PLN Predicted NFZ revenues (nominal) 76,455,275,639.61 79,152,686,845.53 Integrated care – estimated for the whole population 9,907,226,645.39 10,206,812,459.91 Cost of the pilot 100,559,741.39 98,122,347.78 2020 2021 bln PLN Predicted NFZ revenues (nominal) 81,904,785,682.82 84,330,628,520.94 Integrated care – estimated for the whole population 10,506,398,274.44 10,805,984,088.96 Cost of the pilot 100,684,954.18 103,247,560.58 Source: WB, based on NFZ data, 2015 51 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Contracting and provider payment mechanism 1 The NFZ purchases the extended package of services for the patients. The contractual agreement between the NFZ and the provider defines the responsibilities and obligations of each party and specifies the following: the number of patients covered, services offered according to the new package, the contract value paid, the targets to achieve, clinical and financial reporting requirements, disbursement and payment mechanisms. 2 Providers are responsible for ensuring that all diagnostic tests are received according to clinical guidelines, provided by the NFZ in diagnostic and therapeutic paths or in case of lack of paths – by scientific associations. As such, tests that are not available at the center are referred to pre-selected facilities and specialists. The providers are responsible for following up on referred patients, reporting back results, and for payments of these services. 3 Providers must reach an agreement with diagnostic service facilities and specialists regarding their participation in the integrated care pilot model. The following should be included in the agreement: the list of enrollees in Model 1, revised fees per service, and reporting mechanisms. 4 The name of the external health facility should be documented in the contract signed between the NFZ and the provider. Providers play a gate-keeping role in referring patients to external health facilities and specialists when needed, and ensuring feedback on patients is received from the external health facility. 5 Providers should establish referral and feedback mechanisms to ensure comprehensive and continuous care for the beneficiaries. The centers should use the Health Information System (HIS), developed by the NFZ or providers, to track consultations and lab tests. This includes tracking tests until results are available, flagging and following up on overdue results, flagging abnormal results and bringing them to the health provider’s attention, and proactively notifying patients of normal and abnormal testing results. It is suggested that the validity of referrals (for tests or consultations) is limited to one month. Additionally, the contracted external health facility can access the HIS and report on service delivery upon referral as well. 52 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Provider Payment Disbursements from the NFZ to the provider are made on a capitation basis for each patient enrolled with the provider. Some services are paid on a performance-based budget upon submission of the invoices by the providers every month. The budget is limited and is no more than three times the total Fee-For-Service budget. When a patient with a chronic condition from the Model 1 selected diseases uses specialized care payable under separate OSC contracts, a portion of the additional amount in the capitation rate corresponding to the cost of care for that patient under Model 1 is to be withheld for a 6-month period, counting from each billed OSC consultation. The withholding comes into effect on the date on which the service provider is informed by the payer about accrued situation. During that period, the patient is not eligible for Model 1 category services. Performance-based budget A performance-based budget should be allocated to unit-based billing of the following services: ■■ preventive and educational programs; ■■ selected services in chronic conditions under Model 1: – diagnostic consultations for syndrome complexes from Model 1 disease category; – comprehensive consultations for chronic conditions from Model 1 disease category; – diagnostic tests from Model 1 disease category; – specialist consultations – physician-physician, physician-patients, including teleconsultations for syndrome complexes and chronic conditions from the Model 1 disease category, and; – physiotherapy (optional). A performance-based budget should be allocated to unit-based settlement of services for preventive and educational programs as well as physiotherapy programs. The provider may refrain from implementing the physiotherapy programs in the first year of the pilot due to organizational reasons. 53 PILOT MODEL 1. IMPLEMENTATION MANUAL Financing Implementation of integrated care incentives For implementing integrated care, different incentives can be introduced for the following stakeholders: (i) For healthcare professionals: professional ethics, organizational cultures or financial incentives; (ii) for patients: to maximize health or financial incentives (iii) for NFZ: social codes, social responsibility and financial incentives. Based on the initial development and evaluation of the model’s implementation, it is possible to incorporate patient incentives into integrated care models. Patient incentives can be personalized health care plans, health self-management applications, discounted gym memberships, and reductions to some out-of-pocket expenditures. Bonus for results It is possible for the pilot to introduce and develop measures that assess the quality of care and outcomes that can potentially be analyzed by the NFZ to trigger an additional bonus, e.g. in the form of an increased capitation rate coefficient. Some potential parameters include: ■■ percentage of selected screening tests performed, ■■ percentage of patients with chronic conditions from the Model 1 category who had a comprehensive consultation during the last year, and ■■ patient satisfaction survey results. These indicators can be used as the basis for a bonus calculation, improvement vs. previous results, or in comparison to other service providers involved in the pilot program (the benchmark). These tools may additionally be used as benchmarks for quality and result generation across facilities, and therefore incentivize facilities to improve their performance and share lessons learnt during the initial period of the pilot scheme. 54 PILOT MODEL 1. IMPLEMENTATION MANUAL Readiness and capacity building of providers This component finances providers’ readiness, technical assistance and capacity building in implementing the new package of services. This component finances the following: 1 Improvements in the basic capacity of providers and areas where shortages of supply are hindering the delivery of the extended package, primarily through the hiring of additional health workers, providing new and upgraded medical equipment supporting the delivery of the package, but excluding investments in infrastructure or complex equipment. 2 Short-term refresher courses for training healthcare professionals in diagnosing and delivering of newly introduced expanded packages, clinical protocols, technical on the job training, and use of equipment. Special emphasis is given to training staff on shifting the service delivery model from its current focus on curative care to prevention and education. 3 Technical assistance and personnel training that support program management such as contract management, monitoring and reporting requirements. 4 Upgrading and expanding the health information system and training of staff in the use of software. The capacity building activities can be implemented as separate trainings and support finances under EU funded projects. 55 PILOT MODEL 1. IMPLEMENTATION MANUALReadiness and capacity building of providers There is a need to create a set of implementation tools that support the integrated care pilots. The tools can vary in their stages of development with those currently under development by the NFZ such as clinical paths, communication tools between provider and patient, prevention and intervention tools, management tools, as well as, newly conceptualized tools for rules and control systems, gathering of data and monitoring and evaluation of the models. This is considered a separate activity, one of the very first to be undertaken throughout the pilot model implementation and continued over the course of the pilot’s implementation. The Polish working version of the implementation manual for the providers can be found in Annex 5. Patient stratification tools Case finding – an approach that identifies the population for a specific purpose or treatment e.g. smokers for prevention purposes, the elderly for flu vaccination, etc.2 Population segmentation – Population segmentations is the action of grouping the cohort population based on, both, the kind and the frequency of care required.3 Most physicians segment their population intuitively to deliver better care and prevention, e.g. patients over 75 years old, patients with diabetes. There are many reasons for which grouping the population this way is important: to understand the needs of different population groups, to define the combination of care people need, to enable prioritization, and to allow new models of incentives for the providers. It also allows for better monitoring and redesigning of the approach. There are four approaches to population segmentation: ■■ Risk stratification (Utilization risk) ■■ Age and condition ■■ Social and demographic factors ■■ Behavior. The first and the second approach being the most common. A core rule of population segmentation is that the combined set of unique segments must include the entire cohort population: at every stage of an individual’s lifecycle, the person should be represented in just one segment. People in the same segment must have similar health needs, type and frequency of care, and healthcare priorities. At the same time, each segment should have distinct characteristics that differ from the other segments. Using case finding and risk stratification: A key service component for personalized care and support planning. NHS England. January 2015. 2 How to guide: the BCF technical toolkit NHS, 2014. 3 56 PILOT MODEL 1. IMPLEMENTATION MANUALReadiness and capacity building of providers If these two criteria are not met in the segmentation, it proves to be impractical or misleading for the provider. (6) Healthcare managers and care coordinators must ensure that all the services and care provided to the segmented clusters reasonably meets the needs of every individual in that grouping. (7) Stratification Risk stratification is defined as “a statistical process to determine detectable characteristics associated with an increased chance of experiencing unwanted outcomes” (7) For better management of patients, some elements of risk stratification and disease management should be introduced. A separate risk management model needs to be designed. Risk Stratification is a systematic tool that predicts how the population (or a subgroup of the population) is going to utilize the services and who is most at risk of deterioration or needing higher levels of care8. There are several methods used for risk stratification, however, they are all based to some extent on a co-morbidity assessment: comorbidity being the presence of one or more conditions in a patient. Comorbidities can cause increases in risks and costs of care. It is estimated that a patient with comorbid chronic conditions can cost up to seven times more than a patient with a single chronic condition. It is useful for the health care coordinator/manager to know which patients suffer from multiple chronic diseases. A key benefit of risk stratification, apart from identifying care recipients from a cohort, is creating a communication platform and setting mutual goals between the patients and providers as well as facilitating coordination between the different healthcare providers. Although risk stratification is widely used, it holds a disadvantage of focusing on acute care. Therefore, the risk groupings may not be stable on yearly basis. Moreover, risk prediction tools alone have no impact on health outcomes of the population, they require combination with the proper interventions and behavioral change stemming from the risk assessment. (8) Age and condition segmentation In this approach, the population is first divided into age groups, and then into subgroups relating to their conditions. This approach is preferred by many integrated care providers. It is easy to define and understand, and remains moderately constant throughout time. Despite many advantages, the downsides of this approach include potential for disagreement on the “right” boundaries used for creating the segments. This may cloud the effectiveness of the segments in determining the right care for the grouped individuals. 57 PILOT MODEL 1. IMPLEMENTATION MANUALReadiness and capacity building of providers To perform a valid and reliable age-and-condition segmentation, it is important to include the following in the analysis: (9) ■■ judgement of multiple professionals, e.g. medical, social, public health, and other stakeholders; ■■ an in-depth analysis of the integrated care and social care dataset, and; ■■ a review of internationally applied grouping models. Disease management According to Epstein et al. (1996), disease management refers to “the use of an explicit systematic population-based approach to identify persons at risk, intervene with specific programs of care, and measure clinical outcomes.” (10) Dellby (1996) identifies three parts of disease management: ■■ “a knowledge base that quantifies the economic structure of a disease and includes guidelines covering the care to be provided, by whom, and in what setting for each part of the process; ■■ a care delivery system without traditional boundaries between medical specialties and institutions, and; ■■ a continuous improvement process which develops and refines the knowledge base, guidelines and delivery system.” (11) More recently in 2004, Faxon et al. defined the concept as “a multidisciplinary effort to improve the quality and cost-effectiveness of care for selected patients suffering from chronic conditions” (12) In 2006, The Disease Management Association of America included in their definition the aspect of self-care efforts, and defined DMP as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” Disease Management is part of the Model 1 package. Detailed risk stratification tools should be developed for strengthening and implementing integrated care models. 58 PILOT MODEL 1. IMPLEMENTATION MANUALReadiness and capacity building of providers Project management and monitoring The objective of this component is to ensure an effective and efficient regulation, administration and implementation of the pilot through under the NFZ. This component also improves the effectiveness of the NFZ in contracting with providers. To achieve its objectives, this component finances: ■■ the establishment of a Project Implementation Unit (PIU) operation, including the hiring of personnel, arranging of equipment, establishing operating costs, and provider payment processing. A detailed description of the roles and responsibilities of the PIU is provided in the next section; ■■ program monitoring, the strengthening of the PIU’s ability to monitor providers’ performance including M&E and Health Information Systems (HIS) design, software and equipment, and reporting; ■■ capacity building and technical assistance to the PIU, and; ■■ satisfaction surveys, the potential for contracting an external firm to evaluate the satisfaction of patients and providers with the new model. The NFZ is responsible for overall pilot coordination and management in close collaboration with multiple strategic and implementing partners including PHC providers, ambulatory centers, hospitals, and the MoH. The formation of a Steering Committee is recommended to review and address both strategic and policy level issues arising during the project period. The committee is headed by the NFZ and includes key stakeholders. It is recommended that the PIU is established at the NFZ which is responsible for the day-to-day management of the pilot and acts as both the coordinating unit for the technical implementation of the components and the business office for the pilot. It is responsible for overseeing the following: ■■ planning, execution and oversight of the pilot activities, ■■ financial management of pilot funds including data validation and payments to providers, and ■■ monitoring and reporting on pilot activities and outcomes. The formation of the PIU includes NFZ employees (civil servants), full consultants to the NFZ, and full-time committed employees, hired under the fund of this pilot. The PIU staff have the opportunity, through the pilot, to receive training relevant to their assignments on different processes, such as monitoring and evaluation or financial planning. 59 PILOT MODEL 1. IMPLEMENTATION MANUALReadiness and capacity building of providers The Project Implementation Unit (PIU) team may be comprised of the following members: ■■ Pilot Coordinator ■■ Part Time-Finance and Accounting Officer ■■ IT Chief officer ■■ HIS Officers ■■ M&E Specialists ■■ Field Coordinators ■■ Administrative Assistants ■■ Data Validation Officer Summary of PIU implementation responsibilities, including the following: 1 advisory role in contracting and reimbursing providers for health services provided, 2 supporting and ensuring implementation of pilot activities as per the agreed implementation plan and timeline; 3 ensuring the active monitoring of pilot implementation in terms of performance and quality, 4 developing and operating a Health Information System (HIS) to monitor pilot implementation and achievement of pilot objectives; 5 organizing the evaluation of the pilot using monitoring indicators, analyses and other appropriate methodologies; 6 organizing and delivering the training activities for providers in the pilot, and 7 communication facilitation between the NFZ and providers, as well as support to the providers in communication with the patients. 60 PILOT MODEL 1. IMPLEMENTATION MANUALReadiness and capacity building of providers Summary of PIU’s monitoring and evaluation responsibilities The PIU is responsible for pilot monitoring functions, including planning, implementing, monitoring and evaluating the progress of the pilot, and preparing reports on pilot implementation. Capacity building of the PIU can be done through a combination of knowledge building activities and external technical assistance on contracting, provider payment mechanisms, monitoring and evaluation (M&E), improvement of the MIS, providing and maintaining IT equipment, etc. Diagram 2: Preparation of providers for service delivery Orientation event The PIU familiarizes the Providers with the objectives and implementation details: training, outreach, communication, organizational and reporting changes required. Provider Contract signing The PIU advises on the process of signing contract with providers. The PIU participates in the readiness payment as per the payment schedule. Provider implements readiness plan, performs The PIU sets up HIS equipment, applications, trainings, and verifies readiness outreach activities, and attends pilot trainings of Providers Beneficiary Enrollment & service delivery Providers enroll beneficiaries and deliver services See service delivery arrangements for payment schedule See M&E section for more information 61 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Monitoring pilot implementation is essential for the following reasons: ■■ allows for early identification of implementation challenges and for timely, appropriate corrective actions to be taken; ■■ to regularly inform the NFZ, MoH, providers, and other stakeholders of progress towards the achievement of the pilot objectives; and ■■ helps explain the findings of the evaluation by providing contextual information on how and why the project was or was not successful. Quality indicators are clearly defined and measurable items referring to structures, such as the care environment; processes, such as the care received by patient; or outcomes of care, such as mortality. (13) (14) Desirable characteristics of quality indicators include unambiguity and easy measurability, explicit definition of the population to be included and the context to which they apply, and clear linkages between process measures and health outcomes. (15) Targets monitored by these indicators should be specific, measurable, achievable, relevant and time-specific. (16) Monitoring functions of the pilot Establishing a monitoring system, as part of health information system (HIS), which includes: ■■ annual work plans, targets, outputs, indicators, and outcomes for each component; ■■ baseline data, if available, for each outcome indicator; and ■■ user friendly data entry format and built in methodology that automatically updates the targets, outputs, and signal the achievement gap to alert the implementing agencies. The focus is on systematic data collection on specified indicators and related deliverables providing management and the main stakeholders the extent of progress and achievement of results and the use of allocated funds. The data will be collected and reconciled with the provider databases with a specific focus on service delivery under the extended packages. This enables informed management decisions regarding progress towards achieving project objectives. The program monitoring system relies on regular and accurate data collection and analyses to identify the timely implementation of activities, the achievement of intended results, and positive and negative unintended effects. 62 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Strategic (Outcome level): ■■ setting benchmarks and targets to measure pilot success, and consolidating expected outputs/outcomes of all the pilot components into a unified plan to serve as a reference for monitoring performance against these benchmarks and targets; ■■ establishing a central monitoring and evaluation system for monitoring, measuring and reporting of pilot outcomes; ■■ overseeing the pilot implementation process while serving as a key liaison between pilot development and establishing of monitoring and evaluation system, as well as coordinating internally and externally with all the various stakeholders. Program Level (Output and Input level): ■■ facilitating the development and implementation of specific pilot related monitoring arrangements and setting benchmarks, performance and outcome indicators for measuring success at both the strategic and programmatic level; ■■ developing terms of references (TORs) for external evaluation, contracting and coordinating with the external evaluator and overseeing the evaluation process; ■■ overseeing implementation performance of major monitoring initiatives and linking them to pilot outcomes, helping to recruit relevant experts and personnel, and recommending improvements to raise performance of these initiatives; ■■ ensuring the active monitoring of pilot progress in terms of performance and quality; ■■ collecting, compiling, and tracking data needed for the results framework; and ■■ ensuring the verification and validation of healthcare services at the level of providers and external health facilities. 63 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Diagram 3: M&E framework Inputs and processes Outputs Outcomes Impact Infrastructure; Information Improved health outcomes and communication and equity technologies Governance Intervention access and Coverage of interventions Financing Social and finanscial risk Indicator services readiness Health wokrforce protection domains Prevalence risk behaviours Intervention quality, safety and factors Supply chain Responsiveness Information Efficiency Administrative sources Facility assessments Population-based surveys Financial tracking system; Services readiness, quality, Coverage, health status, equity, risk protection, National Health Accounts Databases coverage, health status responsiveness Data and records; HR, infrastructure, collection medicines etc. Policy data Clinical reporting systems Civil registration Analysis and Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress synthesis and performance and efficiency of health systems Communication Targeted and comprehensive reporting; Regular review processes; Global reporting and use Source: WHO, list of core global health indicators (2015). 64 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Pilot evaluation indicators First, a comprehensive description of the pilot’s results framework is developed, after a preliminary approval of the model, containing the list of indicators for overall pilot monitoring, descriptions of each indicator, the unit of measurement, baseline and target values, frequency of data collection, and responsibility for data collection. The results framework is tracked at a mid-term review for progress and to make appropriate mid-course corrections. At midterm, the appropriateness of the targets, indicators and so forth, are assessed and if necessary, restructuring of the pilot can be considered. An evaluation is carried out to ascertain whether the objectives of a pilot are achieved. The evaluation is carried out also to measure the causal effects of the pilot which informs the NFZ’s policy options for the implementation of integrated model in Poland on a larger scale. Consultancy for technical evaluation As part of the evaluation, the evaluator (i) verifies pilot progress towards the project development objectives; (ii) conducts an independent user-satisfaction survey to inform the results framework; (iii) verifies services received by beneficiaries through independently auditing a sample of health facilities for enrollment registers, volume, quality of services and reporting, and a sample of beneficiary households for verification of enrollment and receipt of services; (iv) determines the effect of the pilot on the household service utilization, and; (v) evaluates the capacity of providers to deliver quality services. The Project Implementation Unit provides the evaluator with the necessary baseline data to conduct the end line evaluation. Data sources include the following: ■■ data routinely collected from the providers through the HIS for the selected indicators; ■■ routinely collected data on primary health care service utilization, gathered from the PHC department; ■■ available data on quality of services including completed quality checklists and quality indicators collected through the HIS; ■■ available data verifying both the quantity of care and patient satisfaction, including completed patient satisfaction questionnaires, and; ■■ results of any past evaluations carried out by the PIU. 65 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation To ensure effective monitoring of the above parameters, pilot program organizers must develop an appropriate IT tool to enable up to data collection and analysis of the facilities. A control group is comprised of the patients not participating in the Model 1, those enrolled with other providers, and patients enrolled with Model 1 providers who opted for the traditional model of care. It is also desirable to evaluate the quality of care in the facilities before and after the introduction of the Integrated Care model to better identify potential impacts. Outcome Indicators The outcome indicators of integrated care, as prior discussed in previous sections, are derived from in-depth discussions on the integrated care models for Poland among the different stakeholders: patients, providers, the MoH, and the NFZ. Diagram 4: Outcome Indicators Patient Experience, Engagement and Adherence Patient Initial Conditions, Processes Indicators (Health) Outcomes Risk Factors Protocols/Guidelines E.g. PSA, Gleason score, surgical margin Structure E.g. Staff certification, facilities standards Source: Prof. Michael Porter presentation during OECE Health forum, Paris 2017 66 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation The outcome indicators for integrated care evaluation in Poland are based on international benchmarks, but adapted for the Polish context taking into consideration the available data in Poland, and expert opinions on the reporting systems available. Instead of replacing existing reporting structures, the indicators seek to utilize these in a more efficient manner. The characteristics of the selected indicators are as follows: ■■ Feasible – indicators are already collected by more than one country ■■ Scientifically sound – indicators are valid and reliable ■■ Interpretable – allowing a clear conclusion for policy-makers ■■ Actionable – can be directly implemented by the health care system ■■ Relevant – Reflect important health conditions in terms of burden of disease, cost of care or priorities of health policy Outcome indicators are key for macro-level analyses carried out by the MoH, and can contain important information on a range of factors, both at the national and system level. However, the importance of these indicators should encourage careful assessment and time allocation for their analysis. For the Model 1 evaluation, process measures and outputs could be more useful as they refer to the organizational or individual level. 67 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation The integrated care model is evaluated according to several domains: Table 12: Integrated care evaluation domains Indicator Area of Proposed area of Indicators value Evaluation monitoring 0–1 Access to care Access to care – measured by Number of days to meet primary the access to primary health care health care team/ doctor for chronic doctors. patients. 0–1 Care coordination Presence of the care plan, presence Presence of the care plans for the of the integrated care heath team main dispensary group of patients; (nurse, doctor). creation of the health team. 0–12 Continuity of care Care pathways. Number of chronic and prevention pathways implemented. 0–1 Patient-centered care Support for self-management and Communications plans & prevention prevention activities. plans (health check-ups) Community based care N/A for this model N/A for this model 0–1 User experience (patients Patient’s and medical personnel Survey conducted at the beginning, and medical personnel). satisfaction survey. mid-term and end of the pilot’s implementation. 0–1 PHC integrated care Evidence based service delivery. PHC integrated care management management tool, IT tools. tool, IT tools. Source: World Bank, 2017 Table 13: Model 1 outcome indicators Indicator Benchmark 4 Year Implementation Shorter waiting times to the specialist — 30% Shorter (11 diseases) Health of the population covered — % of unstable chronic patients Patient’s and medical staff satisfaction — Higher by 30% Source: World Bank, 2017 68 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Table 14: Pilot Model 1 output indicators Indicator Minimum Maksimum Number of facilities participating in the pilots 50 150 Number of patients participating in the pilots 250,000 500,000 Clinical pathways implemented 2 20 Care plans for chronic patients N/A 50% of Population Covered Number of regions covered with the pilots 10 16 Percentage of organizational plans implemented — 95% on PHC level Source: World Bank, 2017 Quality Indicators Indicators of quality of care and coordination reported by the entity participating in the pilot. Table 15: Indicators of quality of care Area Subject of Indicator Meaning Measurement Value monitoring mechanism Structure Population availing Number of patients Number exceeding Declarations of Value of Primary Health declared per GP 2,000 corresponds to an Patients under Care excessive number of visits care and becomes limiting on their duration Structure Population availing Proportion of patients in Children under 7 years of Declarations of % of Primary Health each age group age and people over 65 Patients under Care years of age statistically care require a greater number of visits per year Structure Primary Health Percentage of patients Family medicine team’s Declarations of % Care doctors declared to a Family preferred model of care Patients under with relevant Doctor care competence Process Waiting for a visit Percentage of patients Limitation of night and Patients’ % to the PHC in case admitted on the day of holiday healthcare (NOCH) satisfaction of urgent patient’s application and hospital emergency survey need care (SOR) visits and threats to life and health Structure Ensuring continuity Percentage of patients Improving the quality of Report of % of care admitted at PHC to the care performance doctor of their choice fulfillment 69 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Area Subject of Indicator Meaning Measurement Value monitoring mechanism Result Children and Percentage of completed Reduction of infectious Report of % adolescent compulsory vaccinations diseases performance vaccinations among children and fulfillment adolescents up to 19 years of age (by age group) Result Adult vaccinations Percentage of influenza Reducing the epidemic Report of % vaccinations in specific of influenza and its performance age groups complications fulfillment Process Cardiovascular Percentage of completed Detection of s-n diseases Report of % disease prophylaxis Prevention Program for at an earlier, asymptomatic performance Cardiovascular Diseases stage fulfillment (CHUK) preventive testing among qualified dependents Process Cancer disease Percentage of completed Detection of cancers at an Report of % prophylaxis cytology, mammography earlier, asymptomatic stage performance and colonoscopy fulfillment testing among qualified dependents Structure Usage of IT tools Access to the electronic Indicator of the effectiveness Declaration Yes / No medical records (EDM) of the exchange of medical followed by for each authorized information within GP/PHC audit results employee at the location team and in DM programs Structure Usage of IT tools Access to the EDM for Indicator of the effectiveness Declaration Yes / No constituting specialists of the exchange of medical followed by working in other locations information within GP/PHC audit results team and in DM programs Structure Usage of IT tools Possibility of electronic Indicator of the Declaration Yes / No ordering laboratory tests effectiveness of the flow of followed by and receiving results medical information audit results Structure Usage of IT tools Possibility of electronic Indicator of the Declaration Yes / No ordering and receiving effectiveness of the flow of followed by results imaging tests medical information audit results performed outside the institution Structure Interoperability Possibility of electronic Indictor of the effectiveness Declaration Yes / No registration of patients of coordination of medical followed by for services realized care audit results outside the institution (e.g. scans) Structure Interoperability Access to data from Indicator of the Declaration Yes / No Integrated Patient effectiveness of the flow of followed by Information System (ZIP) medical information audit results for the coordinating subject Structure Interoperability Percentage of patients Indicator of the Declaration Yes / No with valid phone numbers effectiveness of followed by communication with audit results patients 70 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Area Subject of Indicator Meaning Measurement Value monitoring mechanism Structure Interoperability Percentage of patients Indicator of the Declaration Yes / No with valid e-mail effectiveness of followed by addresses communication with audit results patients Result Patient and medical Survey carried out at the Subjective assessment of Survey Determined staff satisfaction beginning and at each quality of care, comparison for each survey year of the pilot program with institutions outside the question Held by the institution pilot Structure Accreditation of Posiadanie przez Guarantee of better Certificate Yes / No PHC/ International instytucje organized care Organization for Standardization (ISO) Source: World Bank, 2017 Table 16: Indicators of coordination Area Subject of Indicator Meaning Measurement Value monitoring mechanism Structure Population of Percentage of patients with Rate of the Patients data % chronically ill diagnosed chronic diseases covered effectiveness of by disease management programs detection of chronic in specific age groups diseases Structure Population of Percentage of patients diagnosed Rate of the Patients data % chronically ill with chronic diseases not covered effectiveness of by DM programs in specific age detection of chronic groups diseases Process Care of chronically ill Percentage of children and adults in Early detection and Report of % covered by Disease different age groups covered by the intervention among performance Management health check-ups risk and chronic fulfillment diseases groups Process Care of chronically ill Average patients’ waiting time for Shortening queues to Order date – Number of covered by Disease consultations with other physicians specialists execution date days Management within the DMP scheme Process Care of chronically ill Percentage of patients surveyed Better planning of Patient % covered by Disease for satisfaction because of balance care and its costs category Management testing and comprehensive advice Process Care of chronically ill Percentage of chronically ill patients Ensuring better Patient’s data % covered by Disease using the DM program per disease coordination of care Management group for chronic diseases Process Care of chronically ill Percentage of patients within DMP Rate of effectiveness Report of % covered by Disease with completed comprehensive of care delivery in performance Management Program advice in accordance with Individual DMP model fulfillment Medical Care Plan (IPOM) 71 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Area Subject of Indicator Meaning Measurement Value monitoring mechanism Structure Care of chronically ill Possibility of electronic registration Rate of effectiveness Declaration Yes / No covered by Disease in advance for IPOM benefits of care delivery in and then the Management Program DMP model result of the audit Process Care of chronically ill Percentage of patients in DMP Rate of effectiveness Report of % covered by Disease schemes who underwent of care delivery in performance Management Program consultations with other specialists DMP model fulfillment (separately doctor-doctor and doctor-patient) in accordance with IPOM Process Care of chronically ill Percentage of DMP patients with Rate of effectiveness Report of % covered by Disease educational advice according to of care delivery in performance Management Program IPOM DMP model fulfillment Process Care of chronically ill Percentage of DMP patients with Rate of effectiveness Data from the % covered by Disease information regarding pharmacy of care delivery in National Health Management Program purchase of prescribed medication DMP model Fund and OSOZ Process Care of chronically Percentage of patients using OSC Rate of inclusion Data from the % ill not covered by clinic services outside the pilot effectiveness of National Health Disease Management chronically ill within Fund Program DMP Process Care of chronically Average waiting time for an initial Access rate to OSC Data from the Value ill not covered by visit in selected OSC clinics care outside the pilot National Health Disease Management Fund Program Process Care of chronically ill, Ratio of number of admissions in Rate of the Data from the Value both covered and not NOCH and SOR by chronically ill effectiveness of National Health covered by Disease covered and not covered by the implementation of Fund Management Program DMP care within DMP model Process Care of chronically ill, Ratio of number of hospitalizations Rate of the Dane NFZa Value both covered and not among chronically ill covered and effectiveness of covered by Disease not covered by the DMP – planned implementation of Management Program and unplanned care within DMP model Process Care of chronically ill, Ratio of number of re- Rate of the Data from the Value both covered and not hospitalizations within 30 days effectiveness of National Health covered by Disease of hospital discharge among implementation of Fund Management Program chronically ill covered and not care within DMP covered by the DMP – planned and model unplanned Process Care of chronically ill, The length of time hospitalization Indicator Data from the Value both covered and not chronically covered and not covered effectiveness of care National Health covered by Disease by the DMP delivery model DMP Fund Management Program Result Care of chronically ill, Comparison of average values of key Indicator EDM Reporting Parameter both covered and not clinical parameters in representative effectiveness care values covered by Disease groups of patients with institutions model DMP Management Program participating and not participating in the pilot 72 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Area Subject of Indicator Meaning Measurement Value monitoring mechanism Result Care of chronically ill, Comparison of the average cost Indicator Data from the Value both covered and not of drugs reimbursed and non- effectiveness of care National Health covered by Disease reimbursed at representative- delivery model DMP Fund and Management Program groups of chronically ill covered and OSOZ not covered by the DMP Result Care of chronically ill, Comparison of the average annual Indicator Data from the Value both covered and not cost of benefits reimbursed effectiveness of care National Health covered by Disease by the National Health Fund in delivery model DMP Fund Management Program representative groups of chronically ill covered and not covered by the DMP Result Care of chronically ill, Comparison of the average Indicator Data from the Value both covered and not consumption of selected drugs effectiveness of the National Health covered by Disease used in chronic diseases with guidelines Fund and Management Program representative groups of patients OSOZ with institutions participating and not participating in the pilot Result Care of chronically ill, Comparing the mean cost of care in Indicator Data from the Value both covered and not a calendar year with representative effectiveness of care National Health covered by Disease groups of patients chronically delivery model DM Fund Management Program covered and not covered by the DMP Result Treatment of Comparison of average consumption Indicator Data from the Value respiratory infections of antibiotics in acute respiratory effectiveness of the National Health tract infections in representative guidelines Fund and groups of patients with institutions Nationwide participating and not participating in Health Care the pilot. System (OSOZ) Source: World Bank, 2017 73 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Developing reporting mechanisms Reporting mechanisms are enhanced and include the following: ■■ monthly reports from providers to the PIU, ■■ quarterly reports from the PIU to the MoH, ■■ quarterly reports from the PIU to the steering committee, and ■■ an Annual Pilot Implementation Report, consolidating progress of the pilot implementation by each of the institutions involved, based on administrative data, survey data, beneficiary assessments and independent evaluations. Monitoring is a continuous function carried out by the PIU, with support from the NFZ HIS team. Specifically, it comprises of two parts: ■■ (i) results monitoring of the pilot using the results framework with the specified indicators, and ■■ (ii) evaluation of the pilot. Health Information System Modules The Health Information System (HIS) is an integral part of the M&E system. HIS is a comprehensive system composed of different modules (shown in Table 17) that allow providers to track the patients throughout the different phases of the pilot i.e. from outreach, through enrollment, to service delivery at the PHC level and referral services received in the other facilities. Providers are expected to input all beneficiary related data into the HIS modules. Accordingly, the service delivery data entered by the provider in the system is the source of enrollment, baseline, administrative, utilization, medical history, and referral and indicator data for monitoring. 74 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Table 17: HIS modules pertinent to the pilot Module Function Primary User (Data Input) Outreach Module Identify all outreach activities data including phone calls, home visits, Provider gatherings etc. carried out to recruit beneficiaries. Enrollment Module Gather all enrollment data including active patients and their Provider demographics. Service Delivery Gather administrative and service utilization data including Provider Module appointments given to beneficiaries and services delivered during health visits. Electronic Medical Gather all health information related to the beneficiary including patient Provider Record history, diagnosis, doctor’s notes etc. Lab results/X-ray Collect all results of lab tests and x-rays performed for the patient. Provider results/Drug module The drug module contains details on drugs prescribed to beneficiaries. Referral Module This includes data on all referrals performed by the provider to external Provider health facilities. Questionnaire module This module contains all questionnaires that need to be filled by the Provider/PIU provider or relevant PIU staff. Provider questionnaires may include a baseline questionnaire, risk assessment survey data, patient satisfaction, etc. Spot check reports and field reports by PIU field coordinators are also included here. Training/Capacity NFZ Building Module Reporting module This module allows providers to push reports to PIU, allows PIU staff to No reporting needed, this perform data analysis and produce reports on results. module draws data from all modules 75 PILOT MODEL 1. IMPLEMENTATION MANUAL Monitoring and evaluation Reporting Requirements Table 18 presents the various reports that are prepared for monitoring implementation, and to minimize unnecessary reporting in a one-year period. The quarterly reports are submitted only twice, and semi-annual reports only once, in the following sequence: 1st quarter report, semi-annual report, 3rd quarter report, and annual report. Table 18: Reporting requirements Type of Responsibility Recipient Components Report Monthly Provider NFZ/PIU – Services in prevention and education in health financed on a fee for (financial) service basis; data required to determine the capitation rate; – Services provided under Model 1, including those payable on a FFS basis, and; – Other services payable on a FFS basis under the model (e.g., diagnostic consultations). Monthly Provider NFZ/PIU – Approved services financed on a separate basis under performance- (clinical) based budget; – Patients with diagnosed chronic conditions from Model 1 category included in the model; – Patients who received services in OSC clinics and are diagnosed with a chronic condition from Model 1 category included in the model, with an itinerary of information on the timeframe, location, and provider of service, and; – Specification of patients on waiting lists for the first visit in OSC clinic, diagnosed with a chronic condition from Model 1 category (together with the waiting time). Annual Provider PIU Patient satisfaction survey results. report Source: World Bank, 2017 Sources of Data Sources of data include: ■■ routine data collected through the claims processing system; ■■ data routinely collected at health facility level; ■■ additional data collected by providers and NFZ, such as from enrollment registers, spot checks and ad-hoc surveys; ■■ information collected during the verification processes; and ■■ data from the PIU rapid facility assessment. 76 PILOT MODEL 1. IMPLEMENTATION MANUAL Information technology (details in annex 4): The role of information Technology in providing Coordinated Healthcare: ■■ ensures effective financial settlements with the Payer, ■■ provides the Payer (Supervisory Body) with information about the effectiveness Integrated Care (IC), ■■ provides patient’s coordinator with access to health data in the fullest possible scope, ■■ provides for data exchange between clinics cooperating under IC, ■■ works as a tool that ensures efficient organization of IC, and ■■ works as a tool for contacting and cooperation with patients covered by IC. Addressing needs through IT solutions ■■ Improving the Payer’s reporting system through: – financial settlements, and – reporting on medical and epidemiological data. ■■ Expanding functionality of the Payer’s Integrated Patient Information System (ZIP) system through: – speedy acquisition of data about events regarding patient, and – absence of other sources of such data. ■■ Expanding local IT systems at healthcare coordinators’, – by managing population covered by IC, – data exchange between participants of IC consortium, and – tightening relationships with patients through 2.0 portal (with feedback). 77 PILOT MODEL 1. IMPLEMENTATION MANUAL Information technology Settlements with the Payer – analytic conclusions: The adopted solutions shall not disturb settlements with service providers outside of IC pilot. ■■ All financial needs may be satisfied using slightly modified DEKL (declarations) and SWIAD (services) messages: – DEKL data refer to population covered by healthcare, and – SWIAD data specify service details. ■■ Instead of periodical transfer of DEKL data – implementation of on-line network service for immediate data update; ■■ Medical data constraints need to be considered: the law restricts the scope of data processed by NFZ, therefore – relevant analyses may be implemented through pilot, and – some data can be transferred through consolidated ZBPOZ (consolidated data about PHC services) message, without assignment to specific patient. Settlements with the Payer – further actions ■■ Prior to launching the pilot, the following operational areas should be addressed: – Expand DEKL message or implement network service? – How the Coordinated Healthcare consortium structure should be defined in terms of IT? – What new types of services should be registered in SWIAD message? – Which medical data should be transferred to SWIAD (assigned to patient) and which to ZBPOZ (consolidated)? ■■ Revision of relevant regulations by the Minister of Health and President of the NFZ, and ■■ preparation of NFZ IT Systems. 78 PILOT MODEL 1. IMPLEMENTATION MANUAL Information technology Monitoring the patient’s health status: ■■ data collected in IC facility or consortium: – originating from coordinator’s system. ■■ Data regarding services provided outside of IC facility or consortium, such as – hospital stays; – appointments with specialist physicians outside of IC consortium; – issued and realized prescriptions on refunded medications, and; – commissioned and purchased / refunded medical products. ■■ Where should data come from? – From ZIP system, and in the future also from regional systems, i.e. P1. ZIP system – necessary upgrades: ■■ Module for granting authorized access to patient’s data: – patient decides who is authorized to access data, and – patient may restrict access to certain data (i.e. psychiatric treatment). ■■ Ability to generate data regarding patient from ZIP to coordinator’s IT system: – upon patient’s consent. ■■ Accelerated flow of information in the healthcare system: – info on hospitalization (at admission rather than a month after release), – info on purchased medications (immediately after purchase rather than two weeks later). IT solutions of IC organizers – stage 1 ■■ Provision of the following: – service of capitation lists, – ongoing registration of provided services, – integrated settlements with NFZ in line with relevant requirements, and – keeping electronic schedule of appointments. ■■ Technical service providing for system’s development and operation put in place. 79 PILOT MODEL 1. IMPLEMENTATION MANUAL Information technology ■■ Further recommendations when IC begins include the following: – adjust the system to modified DEKL and SWIAD messages (potentially ZBPOZ), – adjust the system to new network services, and – provide for selection of patients to well-care check-up. IT solutions of IC organizers – stage 2: ■■ Patient contact management: – ability to view the history of appointments, – planning of new appointments in line with IPOM, – reminders of scheduled appointments, – control over services provided outside of IC, and – verification of purchased prescriptions – where necessary. ■■ Summary of patient’s health status: – focus on patient’s health rather than traffic he/she generates, – using standards created under the Electronic Platform for the Collection, Analysis, and Sharing of Digital Medical Records – P1 (Elektroniczna Platforma Gromadzenia, Analizy i Udostępniania zasobów cyfrowych o Zdarzeniach Medycznych – P1) project, and – possibility of using SNOMED classification in pilot implementation. 80 PILOT MODEL 1. IMPLEMENTATION MANUAL Information technology IT solutions of IC organizers – stage 3: ■■ Medical data exchange between entities: – transferring settlement data to consortium leader, – development of tools for mutual electronic registration to appointment, – electronic commissioning of diagnostics tests and consultations, – electronic collection of test results, and – exchange of formalized data about patient’s health status. ■■ Patient’s portal: – ability to register to appointments, – access to educational information, – e-mail and video contact with coordinator and physician, and – registration of home measurement data. Future strategic changes in IT system organization: ■■ acceleration of reporting duties to share the most recent patients’ data: data on beginning of hospitalization, purchased prescriptions; ■■ introduction of capitation-based settlements via network services: only information about changes, settlement available immediately; ■■ collecting greater quantity of medical data affecting optimal treatment regimen: medical registers, monitoring treatment results, and; ■■ initiation of cooperation between healthcare and social welfare systems: demographic and epidemiologic changes, synergistic cooperation. 81 PILOT MODEL 1. IMPLEMENTATION MANUAL Bibliography 1. Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2015 – Results. Seattle:; 2016. 2. Główny Urząd Statystyczny [GUS]. Zdrowie i zachowanie zdrowotne mieszkańców. Warszawa:; 2015. 3. Główny Urząd Statystycznu [GUS]. Dziedzinowa Baza Wiedzy – Zdrowie. [Online]. [cited 2016. 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