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management consulting ab
Models of integrated health care and
social services:
A vision about future trends
Göran Stenberg, Director
Procyon Management Consulting AB. Suècia

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This presentation:
Use systems thinking and especially
complexity science or a complex
adaptive systems approach to
understand the integration of health
care and social services.
Some examples from Sweden

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Six rules
Six init ial r ules t o
guide
our sy st em t hink ing
1.Pat ient needs
ex ceeds or ganizat ional
boundar ies
1.One or sev er al
or ganizat ions can be
r egar ded as a sy st em

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1. Under st anding
indiv idual
unfulf lled needs is
necessar y
1. Indiv idual pat ient s
also belong t o
t ar get / pat ient
gr oups.
Under st anding
t ar get gr oups and
t heir needs ar e
impor t ant
1. Sy st em design is
built on a basic
under -st anding of
w hole sy st em fr om
beginning t o end.
Cr ucial is inter sect ion
of dif fer ent pr ov ider s
6. Changing focus of
w or k fr om inside-out t o
out side-in – a shift fr om
get t ing t he pat ient s t o
f t int o the exist ing
sy st em t o let t ing t he
sy st em incor por at e
pat ient k now ledge and
ex per iences int o it s
act iv it ies

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Background
• People w it h
complex needs
fr equently r equir e
cont inuous car e in
mult iple set t ings
• Without
int egr at ion, all
aspect s of healt h
car e and social
car e ser v ice
per for mance,
suf fer s
• The pr oblems
obser v ed – a r esult
of t he pr e-v ailing
mindset ( Nor man 2001)
“When t he map
changes t he
landscape”.
Rat ional t hink ing –
v iew ing
or ganisat ions as
machines

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• A challenger t o
t he pr ev ailing
mindset, v iew s
or ganizat ions as
human sy st ems,
i.e. t hat is human
pur poseful
int er action
COMPLEX
ADAPTIVE
SYSTEMS ( CAS)
• A sy stem is r efer r ed
t o “complex” w hen
it has so many
v ar iables and
int er act ing for ces
t hat it cannot be
under st ood by
t r adit ional t op-
dow n t hink ing and
appr oaches ( Ant hes 2003)

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Problem statement
How can t he CAS
appr oach be used by
manager s to suppor t
t he int egr at ion of
healt h car e and social
car e t o secur e
appr opr iat e car e for
t he benef t of t he
pat ient ?

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Theory and discussion
• The machine model: The t r adit ional w ay of
dealing w it h complex it y is r at ional and
sy st ematic
• Unit s w ould be managed separ at ely
accor ding t o t he r ules of t he machine
model
- if each par t could w or k bet t er, t hen t he w hole should
w or k bet t er ( Mor gan 1986) ATHOMISTIC
• This det er minedly inw ar d focus w ill r esult
in poor or no under st anding of the life
sit uation of an elder ly per son w it h
mult iple healt h and social pr oblems

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• Inst ead of theor ies assuming cause and
ef fect link ages bet w een separ at e par t s, w e
need t heor ies t o deal w it h pat ter ns and
pr inciples ( Zimmer man et al. 1998) HOLISTIC
• CAS is not a t ool box but a model for
t hink ing as a pr epar ation for action
• A foundat ion of CAS is t he impor t ance and
t he abilit y of self or ganizat ion ( Kaufman 1993)
- Creating order without help from the outside

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• When complex ity is at hand: Impossible to
design an opt imal sy st em in adv ance
- t oo many v ar iables t o t ak e int o account ( For sber g et al.
2004)
• Reconsider at ion of st andar d manager ial
t ask s and sear ch for new r ules

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Innovative managers of integrated care
Some guiding principles:
1. Planned appr oaches t o change has been
r eplaced by mor e emer gent w ay s of
w or k ing. CAS agent s – all t he int egr at ed
car e par t ner s – adapt and change
const ant ly w hen t hey face new
cir cumst ances in or der t o maint ain t he
sy st em
1. Agent s in t he local sy st em hav e bot h t he
r esponsibilit y and capabilit y t o act
1. Innov at iv e manager s r egar d t he pat ient as
an act iv e co-pr oducer
- may not only empow er t he pat ient but is also a mean t o
ser v ice quality ( Kellogg et al. 1997)

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1. Sense mak ing is used t o inf uence change in
complex sy st ems ( Snow den 2002)
1. Agent s gener ously shar e k now ledge and
infor mat ion in or der to str engthen t he
ent ir e sy st em ( C.F Tet enbaum 2008) and incr ease
it s t ot al v alue
1. Teambuilding ar e act iv ely pr omoted
- int er -or ganizat ional as w ell as inter -pr ofessional
- of great impor t ance for t he v alue cr eat ion w it h user s
( Edgr en & St enber g 2006)

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1. Under st anding t he unw r it t en r ules help
sy st em designer s t o mov e aw ay fr om
t r adit ional r ules
Tr ad: Pr ofessionals pr imar ily see t hemselv es as w ork ing
independent ly in t heir ow n responsibilit y t o t he patient
New : All healt h and social car e pr ofessionals see t hemselv es
as par t of a t eam in par t ner ship w it h pat ient s t o impr ov e
healt h ( Inst it ut e of Medicine 2007)
1. Manager s cr eate the means for continuous
lear ning ( Senge 1990) and feedback
r egenerat es t he sy st em

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1. Wor k ing r elat ionships bet w een agent s ar e
collegial and built on t r ust
- leading in an integr at ed car e sy st em is about leading
peers
- may mean t hat ow n or ganizat ional int er est s may need
t o be put aside in fav our of t he w hole sy st em
1. Integr at ion is about int egr at ing agent s in a
CAS and t heir dif fer ent t ask s w it hout
r educing the dif fer ences t hat leads t o an
ef fect iv e pr ov ision of t hese t ask s ( Edgr en
2006)

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Conclusion
An integrated health care
system is built upon the
collective intelligence of
different professionals
who use their knowledge
together with the
individual to meet
Individual patient needs
A hierarchal top-down
approach, following
machine model thinking,
does not fit with the
inherent logic of
integration which requires
adapting to local
circumstances.
A CAS approach views
systems as living organisms

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CAS is a powerful
concept but more efforts
is needed to communicate
the potential of the CAS
approach to managers of
integrated care.

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Some examples of integrated health care
organisations in Sweden

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Sweden’s decentralised
Health Care system
20 County Councils
- Responsible for
financing and providing
Health Care services for
the entire population
290 local authorities
- Responsible for social
service, housing and Care
for elderly and disabled

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Components in
the Swedish Health Care System
 Public Health Care System based on an overall goal:
- “Good health and health care for all on equal conditions”
 Social Insurance System partly covering loss of income by illness
 Decentralised system with 20 self-governed County Councils lead by politicians
elected every fourth year
 Financing mainly by County Council direct taxes (70%). The rest is governmental
subsides and patient fees
 90 % public hospitals. 40 % private primary care units
 Freedom of choice of primary care unit (not GP). PCU financed mainly by capitation
based on population profile
 Local authorities are responsible for elderly care, social care and home service.

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Integrated
Health Care
Public Health
High
Specialized
Health Care
Specialized
Elective Health
Care
Specialized
Acute Health
Care
Patient processes
Competence
transmission
acute elective
Region of Skane
Vision – integrated health care

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Medical value added.
Development and
reneval. Distribution
of knowledge
Adequate time
between referral and
care
Reasonable time between
investigation, diagnose
and treatment.
Investigations and
treatments that are
plannable in time,
content and volume
Shortest possible time
between alarm and
adequate pre-hospital
care
Acute grave conditions
or acute seriouse illness
or injuries
Adequate treatment
Improved prognose
Concentrated organization
Process efficiency, free
of disturbance, quality
and concentration.
Acute or elective
severe not frequent
diseases or injuries
Elderly, children and
youths. Chronical diseases
or common health care
problems
Local
health care
Specialized
acute health care
Specialized
elective health care
Highly specialized
health care
Accessibility
Co-operation
Result
Effects
Needs
Nearness
Accessability all day
around
Improved health status.
Confident population.
Teamwork between
competences needed
Some charateristics of integrated health care organisation
in Skåne
Finance
Spec.LA
PCU
Pat

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Integrated teams at the ED in Malmö
Support and making it easier to estimate the patients
need of care and level by using
the right competence of
professions
• Self care advice
• Triage
• Collaboration
between GP/PC and
hospital
Advice nurse
• Admittance to ward
• Contact with
physician, ward and
relatives before
admittance
• Coordinating
discharges
Hospital nurse
• Activity and
functionel estimate
• Estimate the need
of disabilty aid
• Contact with local
community rehab.
Occ. therapist
• Info about the
patient´s social
situation
• Coordinating
community services
• Patient info about
services available
Social worker
• Estimate patient´s
physical capability
• Judge the need of
disability aid
• Rehabilitation
programs before
discharge
Physiotherapist
GP
back
up
Physi-
cian
back
up

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 29 % of all elderly patients with acute needs recieved treatment from
the integrated team. The future expectations is 50 %
 The patients meet the competence they need in the same locality
 Patients as well as professionals are very satisfied with the teamwork
 Promote collaboration between different organisations and units and
the understanding and trust grows
 The flow of information between the units has improved
 The locistic has improved, the time spent in the ED is reduced, a
growing number of patients can be referred back home and quality in
home care has improved.
Some results with the integrated team

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 Care for elderly patients in the ED has a clearer focus
 Many patients by pass the ED directly to the medicine ward
 The physiotherapist in the triage estimate the patients need
for treatment or disability aid.
 Collaboration around relevant aid e.i wheel chair for the
patient. Functional estimates improves the quality in home
care.
 Advicing nurse sees 20 – 30 acute patients per day (10 %)
ledading to shorter waiting times.
Some more results with the integrated team

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TioHundra AB i Norrtälje - Stockholm
Norrtälje
Local community
Stockholm
County Council
Purchaser
Private GP-s Primary Care incl. GP
Hospital Care incl. ED
Social services
Elderly Care
Home Care
Public Company
”TioHundra AB”

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TioHundra AB – Norrtälje - vision
 ”It is time to think in new ways. We will create a
patient oriented organisation”.
 Responsibility for the local population and financiation
 Increased focus on health and functional ability
 Integrated health care and social care organisation
 New possibilities to boarderless collaboration around
users/patients to solve their health and care needs.

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TioHundra – some resultats
Elderly care
 Shorter waiting times to homes for elderly
 Half the number of waiting patients/users
 Improved quality of care and lower costs
 The number of beds needed has been reduced
 Home service has improved in collaboration with
home care
 Quality and users satisfaction are in some areas
above avarage in Sweden

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TioHundra – some resultats
Phychiatry
 Community and County Council phychiatry in the
same organization
 New developments of care outside hospital –
reduced beds needed by 40 %.
Rehabilitation and elderly care
 All physioterapists, occopational therapists and
other rehabilitation competences in the same
organisation – increased effeciency and lower
costs

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Some identified barriers
- structural - organisation culture
- profession culture - IT
Exemple of bridging dimensions:
- hub function - common house
- physically close - uniform financing
- collected range
Findings in studied integrated care
organisations in Europe

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Patient perspective as driver force for organising
Most care needs to be taken care of outside hospitals
Defiended population or patient groups/target groups
Management task to bridge barriers
Incentives supporting commom actions:
 Common task- clear assignment and targets
 Collaboration is a natural part in the culture
 Knowledge of each others different conditions
 Combination of monetary och non monetary incentives

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Innovation in health care system
Integrated organisation
Patient Processes
Target groups
(Patient groups)
Specialities
Competences
Health care units
Patient results
Production
results

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Managed and organised from a patient
perspective
Compensation based on patient results
Patient
process
Units, clinics etc
Resultat messured as:
Cost, use of resources, production e.i
number of patients, visits, bed days,
treatments, re-operations, returns,
mortality etc
Managed and organised from
a production perspective
Patient
need
Results in
terms of:
Medical quality
Patient
satisfaction
Quality of life
Cost efficiency
From producer perspective to
patient perspective

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Corner stones
Patient
results
Patient
groups
Patient result
based
compensation
Patient
processes
Professional
self control
Leadingtobett er…..
Basedon….. Compensatedfr om…..
Through…..

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Quality
Cost
Higher OK Lower
Lower Bonus Bonus Investing in
quality
improvement
OK Bonus Compensation as
agreed
Quality
development
Higher Cost
improvement
Rationalization Question/
terminate
”To create new relations between cost and quality”
Compensation model

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