Joint Consultation within outreach clinics: What if the solution is the problem?
Treating complex care in hospitals and simple care in a primary care setting, that’s the ideal situation. General practitioners and medical specialists are using lots of projects to
try and refine this by offering simple specialist care at the GP’s practice. What this means is that the cardiologist, dermatologist, geriatrician or other specialist spends a few hours a week seeing patients in their GP’s practice. These so called outreach clinics are the buzzword linked to this phenomenon. At first glance, it doesn’t seem all that bad. It brings care closer to the patient and that is what we all want. But we also want better care at lower cost and unfortunately, that isn’t what the joint consultation model within a outreach clinics always delivers. It isn’t that strange; we’re not really doing what we should be doing: integrating care so we can achieve real improvements. In this blog we’re going to have a closer look at the concept outreach clinics. We will show you the pitfalls and give tips on how you actually can achieve better healthcare results, better patient experiences and lower costs – the triple aim outcomes.
What is an outreach clinic?
An outreach clinic means basically moving care from the hospital to the GP’s practice. We’re talking about care for which we don’t need advanced, expensive equipment. The idea is that the specialist might as well go to the patient to do this. An outreach clinic can be seen as a first step to letting go of the old way of thinking – secondary versus primary care. Those who support the concept of outreach clincis say that this way of working isn’t just cheaper, it’s also a lot more comfortable for patients. It doesn’t take as long for them to get the help they need, and they don’t have to make any contributions based on deductibles. But that’s theory, and practice has shown us something different, unfortunately. How come?
Outreach clinics: what’s going wrong?
We make a few mistakes when designing outreach clinics:
Outreach clinics fall into the same category as population management, network care, care coordination, managed care, disease management, substitution of care and transmural care. It’s not a synonym for these terms, but part of them. You can say that outreach clinics are part of substitution of care which in turn is part of integrated care concept care network. Outreach clinics are a small piece of a complex puzzle that could be integrated care. Because all these terms are used interchangeably, it leads to a lot of confusion.
Outreach clinics means thinking in boxes
When outreach clinics were created, this was the line of reasoning: the care system surrounding the hospital and primary care practice is too fragmented to offer good healthcare for vulnerable patient groups, so our solution is going to develop mini organisations who are going to solve this issue. Then we are going to discuss whether and to what degree that should be generalist or specialist care. What we are actually doing is adding another barrier without changing anything fundamentally. In other words, adding another box to the previously existing boxes.
Shortcommings of disease management
Disease management is still the basis for a lot of integrated care activities, when a crucial mistake was made when it was first introduced in the Netherlands. We forgot to take into account the medical specialist into the bundeld payment scheme, which has meant the desired results in terms of quality improvement and cost reduction weren’t met. Yet, there’s another way! In countries where integrated care is successful, health insures or governments make financial agreements primary and secondary care to enhance the development of integrated care networks. As long as we don’t have any integrated payment incentives, the shortcomings of integrated care will keep coming for us. The consequence is that people will continue to introduce new hypes, like outreach clinics, to try and find a model that does work.
Who is ‘in the lead’?
Is it the GP or the medical specialist (the hospital) pulling the strings? Often, there aren’t any clear agreements on this, which negatively affects the cooperation. Generally, there will also be different interests from different stakeholders, which stands in the way of a fruitful cooperation.
Data sharing between healthcare providers is essential to be able to work together effectively. In the Netherlands, however, data sharing between care providers is incomplete and fragmented. This makes it nearly impossible to gain insight into the current and future care demands and new care initiatives tend to miss the mark.
Process instead of outcome based guidance
When (re)designing the care process, too often we use a disease-specific perspective instead of the needs and wishes of and outcomes for the patient. In addition, measurment initiatives predominantly focus on process indicators instead of outcome indicators, when the latter should be the basis for care improvement and innovation.
What should we do?
Outreach clinics are (partially) a reaction to the failed introduction of integrated care. It was created from a policy-related paradigm instead of from the perspective of the patient. This made it doomed to fail. If we want a serious solution for the problems our current healthcare system is facing – rising and increasingly complex healthcare demands and healthcare costs that are through the roof – we need to choose an integral approach: interated care networks. But how do you go about integrated care networks? Here are four tips:
Tip 1: Are you willing to take a risk?
In an integrated care network, all those involved have their own role and jointly carry the responsibility for quality and cost outcomes . But are you willing to take this risk as a healthcare provider? Hospitals are better able to handle these risks than primary care practices. What’s really important is that all care providers that are involved in an integrated care network agree on the care, the division of responsibilities and measuring results. A number of best practices have shown us that it works for complex patient groups if you organize the care along the entire continuum of health and social care and make people collectively responsible for the outcomes. Then you will profit from taking joint risks in the end!
Tip 2: Go for results: Triple Aim outcomes
Specify the desired outcomes, use the Triple Aim philosophy as your guideline. The Triple Aim approach is about improving your outcomes in terms of quality, health and cost. To achieve the desired outcome for a specific (sub)population, you work with a group of healthcare providers in a coordinated way and you share the risks. You are all jointly responsible for whether or not you achieve the quality and cost outcomes you are aiming for.
Tip 3: Culture eats strategy for breakfast
Cooperation and shared responsibility aren’t always easy. It demands trust, openness and transparency. To make integrated care networks a success, it’s important that the individual interests are clear and there are clear agreements. Define a shared ambition together, link your goals to that ambition and make sure there is support amongst all partners. You can create this support by building trust. Map out how this joint ambition contributes to achieving the goals within a network. Make sure you have a safe culture where people are willing to stick to the agreements and aren’t afraid to speak up if something goes wrong. In short: make sure the ‘soft’ side within your care network is in order.
Tip 4: Make agreements about the top 3 pitfalls
You need clear agreements about financing, data sharing and organizational interests to increase the chances of a successful cooperation. Agree who registers which data and how it’s analyzed and with what goal. And be aware of the differences in organizational interests between medical specialists and GPs. For medical specialists, numbers are important, GPs have more to gain if they create more time in their practice. How can you meet in the middle; how can you help and reinforce each other and create a win-win situation? Start by looking at the healthcare needs in your region to increase the chances of successful cooperation within your local care network.