Mikael Thorberg, Sweden, has authored this blog post with Sofia Widén.
Our team at ACCESS Health International studies how countries deliver high quality and affordable elder care in Europe, Asia, and the United States. When we find promising and successful models, we analyze these models to understand their success. This blog post shares the results of one such study.
The healthcare sectors in many countries are innovating rapidly to meet the needs of aging populations. One of the most important opportunities in elder care is the development of new care models designed specifically to respond to the needs of an aging population. The elderly require care that is long term, integrated across multiple levels, and coordinated among different care providers. This care must be high quality, but it must also be affordable to the payers, be they individuals, insurance companies, or governments.
The ability to deliver on the promise of high quality, affordable elder care is no easy task, but many examples of promising models exist. In this blog post, we profile one such example: Care Company TioHundra, a public healthcare company in Sweden.
A Unique Model
TioHundra provides healthcare, homecare, and social care in Norrtälje, a city in Stockholm County. Throughout most of Sweden, counties oversee healthcare, and municipalities are responsible for providing homecare and social care. The two levels of government fund care separately and often do not communicate with one another, despite responsibility for the care of shared patients. At its formation, TioHundra took a unique approach to providing integrated care. Rather than attempting to coordinate care across multiple organizations and payers, TioHundra merged care providers and created its own payer. TioHundra now operates as one large healthcare and social care system, owned and managed jointly by the municipality and the county. This unusual merger represents one of the biggest regional reforms in Swedish healthcare in over twenty years. TioHundra is the largest employer in Norrtälje Municipality.
Information and Integration
TioHundra aims to integrate the entire care system in new and innovative ways. The objective of the company is to increase efficiency, quality, and safety while reducing the costs of care. As many as sixty people may be responsible for the care of a single elderly patient. Integration between hospitals and social care organizations enables TioHundra to overcome some of the friction and inefficiency that would inevitably result from large and uncoordinated care teams. One of the key benefits of integrated care is the relative ease with which information can flow between different care providers.
Healthcare providers use digital information systems to manage information about patients. Many counties and municipalities in Sweden use different digital information systems that are incompatible with each other. Likewise, a wide digital divide often exists between technologically advanced hospitals and traditional homecare organizations. The integrated structure of TioHundra enables different providers to access timely and accurate information about patients and their care plans. At this time, that information is in read only format. As a single, integrated provider, TioHundra is well positioned to introduce a single electronic health record system that allows different levels of access to different healthcare professionals. The company is exploring options to introduce such a unified system.
Technology alone will not improve the flow of information. Organizational integration is also vital to the seamless transfer of information. The leadership team at TioHundra works across organizational boundaries. A manager can pick up the phone, without hesitation, call another department manager, and immediately solve an issue. The focus at TioHundra is on patient care, not organizational boundaries. This focus on patient care is a crucial element of the integrated care model.
Payment and Incentives
A unified payment system is another key to the success of TioHundra and its integrated care model. Both Norrtälje Municipality and Stockholm County finance TioHundra, but the funds are channeled through a single entity. Elsewhere in Sweden, counties pay for healthcare through one avenue, while municipalities pay for homecare and social care through another. Payment through a single funder supports collaboration between healthcare providers and homecare and social care providers.
An integrated care system can also offer counties and municipalities the opportunity to explore payment models that reward positive health outcomes. The payment system should incentivize care providers to keep patients healthy. Dr. Peter Graf, Chief Operating Officer of TioHundra, recognizes this as an opportunity for improvement to the TioHundra integrated care model.
Many provider payment models encourage extensive care rather than positive patient outcomes. Currently, Stockholm County provides only sixty percent of reimbursements to providers based on capitation. Payments to providers based on capitation can encourage a focus on keeping patients healthy rather than delivering (and charging for) more care. The capitation rate of Stockholm County is the second lowest in Sweden.
It is relevant to question this model since, as Dr. Peter Graf puts it, “more care does not always result in better health outcomes”. An integrated care system is able to take a larger responsibility for patients, since it is a full service provider. An integrated care system along with the current technological development creates new opportunities to reward care organization based on health outcomes rather than on the number of services provided.
Challenges and Opportunities
The population of Norrtälje is aging even more rapidly than the population of Sweden overall. The lessons that Norrtälje Municipality and Stockholm County are learning through the innovations of TioHundra will provide valuable knowledge for anyone interested in the future of the Swedish healthcare system, elder care, and healthcare systems facing similar challenges.
Stockholm County and Norrtälje Municipality established TioHundra in 2006 as an experiment. The merger of healthcare, homecare, and social care at TioHundra is a complex process. The work of full integration is ongoing. Cultural differences across its component organizations add to the challenges of achieving full integration of care. TioHundra has had many successes, but the company is not without critics. Some areas of care have shown only limited progress toward full integration, and hospital readmission rates remain higher than desired. Until 2014, the company had been operating at a loss. Despite these challenges, TioHundra offers a living laboratory in which we can study the ongoing experiment in Norrtälje. The management team of TioHundra has shown a strong commitment to integrated care and sound financial management. The company broke even for the first time in 2014. We will keep an eye on TioHundra as the company continues to grow, continues to learn, and continues to improve how it provides integrated elder care.
Click here to download TioHundra Case Study: Part One.