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.
In my previous blog post, I described the work of the Mobile Team for the Elderly in Uppsala, Sweden, a municipality of two hundred thousand. In this blog post, I will discuss some of the tangible benefits of the Mobile Team to the municipality, to patients, and to patients’ families.
Before I get started, I want to explain how healthcare and government is managed and financed in Sweden. Sweden is organized into municipalities. Several municipalities comprise each county. Uppsala County includes eight municipalities, including a municipality called Uppsala municipality (see the maps below). Uppsala County manages healthcare provision for all citizens in the county. The County Council in Uppsala is the payer of healthcare in the county. An autonomous government governs each Swedish municipality. Municipalities are responsible for social care for the elderly. The Mobile Service offers healthcare to the elderly, thus touching on the responsibility of both Uppsala municipality and Uppsala County. The Mobile Emergency Team serves the elderly only in Uppsala municipality, not the entire county.
Since the establishment of the Mobile Team in September 2011, fewer older patients visit the emergency room at Uppsala University Hospital. The Mobile Team started as a pilot project, which became a permanent unit in Uppsala, in January 2014.
Uppsala University Hospital is the only hospital with an emergency room in Uppsala County. Uppsala University Hospital is a public hospital financed by county taxes. Fewer visits to the emergency room thus save costs for the county. One visit to the emergency room is assumed to cost the county hospital 2,500 Swedish kronor (350 US dollars). In a conversation with the Mobile Team, one of the team’s two physicians, Magnus Gyllenspetz, explained to me that Uppsala County saves costs if the team makes three home visits per day. The savings come from reductions in the number of ambulance trips and the number of treatments provided in the hospital.
The total yearly cost of the Mobile Team is 3.5 million Swedish kronor (five hundred thousand US dollars). Uppsala County saves 2.5 million Swedish kronor (350,000 US dollars) on reduced outpatient treatments of the elderly alone. The largest savings are in the area of reduced hospitalizations for this group. Estimates for 2012 indicate that the Mobile Team saves Uppsala County over nine million Swedish kronor (1.2 million US dollars) annually on inpatient treatments for the elderly, excluding the costs of the Mobile Team.
Without the Mobile Team, an estimated 460 patients would have traveled to Uppsala University Hospital for treatment during the pilot phase, from September 2011 to January 2014. These 460 patients are “avoidable inpatients,” patients who can avoid a stay in hospital with treatment or social care assistance at home.
Apart from the economic benefits, patients like the Mobile Team. Fewer patients need to travel to the hospital. Fewer patients need to wait in emergency rooms. Fewer relatives worry about the health of their elderly loved ones. Fewer relatives must take time from work to help their relatives get to the emergency room. The Mobile Team cares for the ill residents in nursing homes. Because ill nursing home patients are the responsibility of the Mobile Team, the nurses in the nursing home are able to continue to care for all of their patients. If the nurse from the nursing home had to travel with the resident to the emergency room, then that nurse could not care for other patients.
Considering all the benefits, why is there only one Mobile Team with this setup in Sweden? Why do some older patients who need urgent care still travel to the emergency room? Is the Mobile Team too good to be true? How can we explain the fact that there is only one Mobile Team financed by a municipality and a county in Sweden?
There are many answers to these questions. Some older patients feel safer in emergency rooms. Most patients want the freedom to choose where to obtain treatment, at home or in emergency rooms, and some older patients feel safer in emergency rooms. People do not like to be told what kind of healthcare is best for them. Some simply do not know about the Mobile Team. Healthcare personnel follow routines. Some employees of the county do not work with the Mobile Team simply because it is not part of their routine. In my conversation with the five members of the Mobile Team, they expressed a desire to develop a new promotional strategy that would help the team reach out to more patients and partner organizations in the county.
The Mobile Team in Uppsala became a permanent unit one year ago, on January 1, 2014. I hope that other municipalities will establish Mobile Teams in the future, as more people become aware of the many benefits a Mobile Team can bring.
This is a happy thought for the New Year.
Happy New Year to all readers!
 “Final Report on the Mobile Emergency Team for the Elderly, 2013”. Author of the report: Swedish Association of Local Authorities and Regions (Slutrapport för projekt kring de mest sjuka äldre Mobila hembesöksteamet i Uppsala, SKL)
Last week, I traveled to Uppsala from Stockholm to meet the team of the Mobile Emergency Team for the Elderly (Mobile Team). I am in the process of writing an in depth case study of the Mobile Team. This case study is part of our larger effort to identify good practice in integrated eldercare in a number of countries, including Sweden, Singapore, and the United States.
The Mobile Team is a leading example of integrated eldercare. Healthcare professionals can learn from the organization in general, and from its philosophy. As I build this case study, I will share with you some of my experiences with the process and what I am learning. In a series of blog posts, I will tell you about the Mobile Team and highlight different aspects of their work.
The Mobile Team started as a project in 2011, with financial support from the Swedish Association of Local Authorities and Regions. Today, the Mobile Team is financed by Uppsala Municipality and the Uppsala County Council. Uppsala County is located just north of Stockholm County. All members of the Mobile Team are employed by Uppsala County, which covers sixty percent of the total costs of the Mobile Team. Uppsala Municipality covers the remaining forty percent of the costs. Both the county and the municipality raises funds through taxation.
The Mobile Team becomes involved with patient care through several different avenues: Nurses who work in homecare organizations contact the Mobile Team when they need a second opinion on a patient. Employees at care homes for the elderly contact them for advice. And ambulatory personnel coordinate their efforts with the Mobile Team.
The Mobile Team centers on the needs of the patient. The objective of the Mobile Team is to offer urgent care at home to people over the age of sixty five. Many older patients visit emergency rooms at hospitals for urgent but non life threatening care that can be treated at home. Often, these patients must wait for hours at emergency rooms because their illnesses are not as pressing as the illnesses of other patients seeking emergency care.
The Mobile Team performs urgent care right in patients’ homes. The Mobile Team is able to measure glucose, take blood tests, test urine, and perform electrocardiograms in the home. The team can treat patients with a range of drugs at home. They measure blood flow in arteries to assess if the blood circulation provides enough blood to the legs and to the brain. Blood circulation to all tissue is necessary to avoid stroke, for example. The team also measures saturation, or oxygen levels in the blood.
They treat patients with pariboy, an inhaler, if patients experience difficulty breathing. The team also treats minor wounds. When a patient needs treatment at the hospital, the Mobile Team coordinates with the ambulatory service to arrange transport.
Many older patients need support at home from multiple caregivers. The Mobile Team coordinates care with these caregivers, including professional homecare providers. If a patient visits the emergency room for an illness that can be treated at home, a municipal nurse of the Mobile Team, who works at the hospital emergency room, informs the patient of the Mobile Team. If possible, the municipal nurse informs the patient caregivers of the treatment that the Mobile Team can offer at home. If a patient needs urgent care a second time, the caregivers and the patient know about the Mobile Team.
The Mobile Team includes a nurse from the municipality and a doctor from the county. Sometimes, the municipal nurse needs assistance from the doctor to treat patients at home. In turn, the doctor often relies on the expertise of the municipal nurse about the full care plan for a particular patient. For example, the municipal nurse coordinates the effort of the Mobile Team with the effort of homecare teams. The Mobile Team and homecare teams work together to ensure that patients obtain the support they need to stay at home and recover. Both the healthcare and the social care needs of the patient are assessed. Many times, doctors assess healthcare needs in isolation. Homecare teams assess social care needs. The Mobile Team can help provide for these needs by increasing communication between caregivers.
The quality of healthcare delivered to a patient depends to a large extent on the quality of communication between caregivers. This is particularly true for older patients with complex needs. The municipal nurse in the Mobile Team can update homecare providers on new treatment and new medications. Sometimes, the communication between doctors from the county and homecare providers can become delayed. Since the Mobile Team only recruits nurses with experience from municipal care organizations, the nurses in the Mobile Team are familiar with the channels of communication in the municipality. This familiarity speeds up communication and creates added value to patients that obtain care from different caregivers.
The Mobile Team is a critical link in the integrated healthcare chain in Uppsala Municipality. The neighboring municipalities are examining the possibility of establishing similar mobile teams.
The combination of the medical expertise of the doctor from the county and of the network and the experience of the municipal nurse renders the Mobile Team more effective than its constituent parts. Integrated care requires that different care providers collaborate. Different healthcare providers must acknowledge each other, and they must understand each others’ abilities and limitations.
Healthcare professionals cannot become experts in isolation. High quality healthcare at home and the timely transfer of information to homecare organizations improve patient experiences and patient outcomes. The best healthcare at home will not in itself prevent the patient from falling ill a second time. A patient may need help cooking or remembering to take her medication. If the homecare team is not informed or fails to help the patient take her medication, the patient may soon fall ill again. This is just one example of the interdependencies of integrated care models. Each care provider depends on other care providers. Patients depend on multiple care providers.
The Mobile Team collaborates with nursing homes, ambulatory nurses, the emergency service at Uppsala University Hospital, and various homecare organizations. Follow this blog for more information about how the Mobile Service works with other healthcare providers.