The Alzira ModelThe experience of Ribera Salud

Hospital de la Ribera, Alzira (Valencia)October 6th, 2015

Dr. Elisa TarazonaHealth Care Organisation manager

Salvador SanchisHR Director

Carlos CatalánMedical Director

Manuel BoschDeputy Director of Strategy and Development

Summary

An Integration Model Clinical management

HR Strategy

Technological development

Results

Surveys

About Ribera Salud. Leading a process of change

Conclusions.

THE RIBERA SALUD MODEL

PPP Model

Capitated

Payment

Healthcare

Integration

Networking

Key Ideas

AN INTEGRATION MODEL

The Evolution of ourHealth Model Approach

The Evolution Of OurHealth Model Approach

The Evolution of OurHealth Model Approach

The Patient Today

P

A

T

I

E

N

T

PRIMARY CARE

HOSPITAL

HLME

OLD PEOPLE’SHOME

PRIMARY CARE

HOSPITAL

HLME

OLD PEOPLE’S HOME

P

A

T

I

E

N

T

ACUTE

PATIENT

CHRONIC

PATIENT

Most importantly: cultural change of the politician and healthcare organization

managers.

The most important thing is not the hospital.

What really matters is to stand by the whole healthcare network, its professionals

and other agents involved (City Councils, Schools, Nursing homes, old people’s

homes, etc)

To create a corporate culture: Population Health Management

The Integration Model

Capitative payment ….Objective:

“To achieve the best health conditions for the citizens”

S t r a t e g I c t o o l : h e a l t h c a r e I n t e g r a t i o n

P R O A C T I V I T Y

Integrated Primary Care Center - SUECA

Integrated Primary Care Center - SUECA

HRIT

Information Technologies:

Full EMR (all departments and levels integrated)Relationship doctors-patients (Health Portal) Relationship betwen profesional (hospital-Primary Care)t.Business Intelligence System (from professional to corporatemanager).Benchmarking. Cost analytics and what-if capabilities.

.

2 - People

Management:

Training financed by theOrganization, Teaching

(University and MIR) and Research

Incentives system. Career and professional

development

To achive strongerprofessionals´comitment in decision-making processes.

Do the correct in the best palcewith the best quality &EfficiencyChronic Health Plan. Proactivity in CareHome care, social andhealthcare network.Patient Safety Demand Management.

1 Clinical Management:

Triangle for Success

CitizenPatient

Care Giver

Population Healthcare Management: Proactivity• To promote preventive and health

promotion activities • To be proactive in patient’s care • Healthcare management of demand

and needs• Challenge: Chronic Diseases

Management• Segmentation of population

Professional Alignment: Primary Care Doctor – Hospital Doctor

Nurses: new roles, competences and responsibility: emergency triage case history management, etc.

Health objectives alignment across the whole organization

Variability decrease in clinical practice• Healthcare processes, Medical paths• High resolution

Healthcare continuity• Care longitudinally• IT integration

Management of Demand vs Needs Self management tools

• Health website• Florence Direct. To know “all” about your

patient• Inter-consultation • Algorithms; Specialist Consultant (link doctor)• Predictive models

1

Objective: Achieving a stronger professionals’ commitment in decision-making processes

2

3

4

5

6

7

Clinical Management

Best Quality & Efficiency

Kaiser Pyramid of Care

RISKADJUSTMENT

CARE PROVISION ANALYTICS

• Risk adjustmenttools

• CRGs• Predictive Models

• EMR• Case management• Decision tools• E-consultation• TeleHealth• Promoting health• PAthways

• Costs per patient• Utilization per patient• Clinical outcomes• Outcomes that

matters to patients

Right Process, Right Moment, Right Location, Right Risk

Segmentation Projectand Cost per Citizen

Co

mp

lexi

tyC

RG +

+ Cost

CaseManagement

Opportunitiesfor efficiency

Healthypopulation

GoodControl

-

-

We look after citizens’ health,

encourage healthy lifestyles and

strive to offer the best health

care services

Developing and strengthening the necessary knowledge and tools so that the

population can lead a healthy lifestyle, be it individually or in an organized fashion.

Our knowledge as health care professionals in conceptualising actions towards

HEALTH PROMOTION and DISEASE PREVENTION

Who are we?

Aim

What can we offer?

Health Promotion Plan

Health talks

Workshops

Information stands

Conferences

Open doors days

Colaboration with institutions

Media

Contests

Pomotional materials

Chronic care plan+Salud Program

The health portal includes a module to classify patients that will

automatically show the health promotion campaigns that are best-suited to

each profile.

Health PortalPromotion Campaigns

Public Health

• Identification of citizens: vaccinations, check-ups, cardiovascular risk.

• Cancer screening : cervical, breast, colon.

Communication: Writing Committee (Magazine, radio/TV spots, brochures,

“Els Ribera” comic, etc.) World Days (AIDS, tobacco, etc.)

Schools: Health education programme

City Hall: Health Days

Social Services: Social and Health Care Programme (senior citizens’ homes)

Pharmacies: Programmes about the proper use of medicines

Coordination with:

Other Promotional Activities

Activities carried out by health centre professionals.

Updating algorithms, clinical guidelines, “stop doing to

start doing” procedures.

Leaders responsible for pathologies in each basic area.

Ongoing training, follow-up tools.

Evaluation – feed-back with professionals.

Level 1 and 2

Chronic Patients Plan: Levels 1 and 2

Appointments: Hospital /Home-Care Unit / Primary Health Care / Social

Work.

Case management – responsibility of the Primary Health Care nurse

“Shared” patient Primary Health Care Doctor /Internist /Nurse.

24/7 Call-Center.

Digital clinical history to help continuity of treatment.

Managing new technologies.

Level 3. Case Management

Chronic Patients Plan: Level 3

Chronic Patients Plan: Level 3

Chronic Patients Plan: Level 3

PRIMARY CARE - HOSPITAL HOSPITAL - HOSPITALElectronic medical record: Virtual consultation (no patients)

Virtual: Video conferences, call conferences and intranet (e-learning) for clinical sessions, training, etc

On-site:• Specialist-consultant• Rotary training periods in hospital for

family doctors• Family doctors do shifts in emergency

service.

Electronic medical record: On-site and virtual consultations

Video conferences (healthcare network)

Interdisciplinary Committee: • Tumours• Infections• Pharmacy and rational use of medicines• Safety

Relationship Between Professionals

Health Portal

PRIMARY CARE: FAMILY DOCTOR AND

NURSE

HOSPITAL: SPECIALIST AND

CASE MANAGEMENT NURSE

Heath Portal

+ SALUD

External web page (open access)

Personal area “My health e-space”

The health portal “+SALUD”is a new interactive portaldesigned for patients. It is anonline platform wherecitizens can easily access allthe information regardingtheir health and well-being..

HEALTH PROMOTION

HEALTH

MANAGEMENT

Health Portal

Health Portal

The patient access to his/her electronic medical record from anywhere:- Virtual communication of test and citology results- Consultation from abroad- Texting with te primary care nurse and family doctor

Follow up and monitoring:- Cardiovascular risk factors- Diabetes mellitus type 1 and 2- COPD

Telemonitoring: - Cardiac insufficiency- COPD- Diabetes mellitus type 1 and 2

Health Portal

Patients with special needs:

Oncology patients in treatment with chemotherapy: family doctor and

primary care nurse, oncologyst and case management nurse.

Patients with inflamatory rheumatologic deseases in treatment with

biological therapies: family doctor, rheumatologist and case management

nurse.

Patients carrying ostomy: family doctor, primary care nurse and case

management nurse.

Health Portal

H.R. StrategyDiversity Management

Financed by the

organization

Hospitals with MIR (Resident Medical

Intern) and University accreditation

; Professionals as University teachers.

research projects and

performance of clinical trials

Retribution based on post and professional´s development:

training and experience retribution basis

Variable salary

Personalized compensation, “flexible incentive schemes ”

Fix salary

Variable salaryQuantitative work

objetives

Variable salary depending

on activity and aims

achieved by the

professional.

Qualitative work objetives

Healthcare quality and

efficiency criteria: mean stay,

readmission rate…

Flexible incentive

plan

PRIVATE EMPLOYEES

F U N C T I O N A L I N T E G R A T I O N

PUBLIC SERVANTS

Private employees

District Council’s employees

Government’s old employees

Civil Servants

Fix salary

. Common strategic lines

. Criteria for each professionalcategory

STANDARDIZE

. Organization’s aims

. Healthcare administrationALIGNMENT

SIMPLIFY

ADJUSTMENT

FOSTER

. Valuation criteria

. To economic and socialsituation

. Teamwork

. Motivation

. Commitment

OBJECTIVESCONCEPT AND

WEIGHTING SYSTEM

Incentive System

[Ebitda (Earnings before Interest, Taxes, Depreciation and Amortization) Public Healthcare Authority Objective Plan (annual ranking between 24 health depts. that features 35 indicators related to health provision, published by the Regional Health Ministry).]

Concept and weighting system

80%

according tooccupationalcategories

20%for all employees: Ebitda, Objective

Plan, JointCommission, Chronic Plan

100%

Target. Different per

category

Incentive System

Incentive SystemSpecialized care, Associate Doctor

Successive/first consultations ratioTests/first consultations ratioFirst visit delay/waiting timesTests delay/waiting timesDRG case adjusted average stayDRG case adjusted tests/admissionSurgery waiting list0

Incentive SystemPrimary Care, Associate Doctor

GFAR - efficient and effective prescriptionVaccination coverageHealth e-Space

Centre’s balance sheetExpenditureAscribed populationHR costReferrals to hospital units

Remunerative SystemResults and Conclusions

Results

Personnel costs represents 45-50% of the company’s total expenditure

Bonus remuneration amounts to 20% of personnel total expenditure. For the doctors

category it can reach up to 35-40%

Last year, meeting of objectives averaged 94%

Conclusions

Adjustment: the variable system allows personnel costs to be adapted to the organization’s

outcomes and the quality of service we deliver.

Equitative: it recompenses the best and hardest workers in the organization.

Commitment: it fosters the development and long-term commitment of people within the

organization.

Balance: it aids tailoring the staff to real activity. The bigger the team, the lower individual

variable remunerations are.

Our incentives system is a key factor in talent attraction.

Technological Development

Forthe Citizen

Forthe Professional

Forthe Manager

• SMS notice

• Touch screen

• Emergency waiting time

• Simultaneous translation

• Family patient information

• Electronic medical history

and digital radiology

• Integrated processes.

“Florence directo”

• Medical History access from

mobile phone

• Telemedicine. Teleworking

in radiology

• Quality evaluation

• Emergency response time

• Services and professionals

workloads

• Technology and

management

• Systems innovation

Ribera Salud toolsSupport for Professionals

Online access from the nursing homes

• Hospital’s admissions-appointment module (Florence)

• External consultation proposals• Test requests• Consultation without patient referrals• Algorithms• Florence direct: automated information system• Hospital discharge. Online history• Pharmacy and medical material attribution

• Access to SIA Abucasis from Florence• Registration of all vaccinations in RVN• MPRE module for consultations and prescriptions:

(emergency room, external consultations, out-patient surgery, hospitalization…).

• IT module, hospital prescriptions• Abucasis agendas used for appointments (emergency

room, pediatrics, hospitalization...). As an agenda manager (not for citizen)

Social and health centres, (homes of residence)Inspection: Electronic visa, IT follow-upPublic Health

Comunicaciones

Sistemas de Base (Windows XP/7)

Intranet Corporativa

Po

rtal

de

l Ciu

dad

ano

Gestión Económica y

Logística(Navision)

Gestión RR.HH

(Meta4)

Clínico Gestión

CMI Costes Reporting Iasist

PA

CS

(Car

estr

eam

Ph

ilip

s)

Lab

ora

tori

os

(Un

ilab

as)

Áre

as C

ríti

cas

(Dra

ger)

Ne

fro

logí

a (N

efr

olin

k)

Car

dio

logí

a (P

hili

ps)

…

SIP

RCLE

CMBD

ACTIQUI

SISAL

COMPAS

HEAVS

SIDO

ComunicaciónImpresiónCorreoOfficeOfimática

Gestión Asistencial ( Florence)

Estadística y Gestión

(Cognos)

Consellerí

a

GAIA

SIA-Abucasis

Lab-Online

General Idea– APLICATIONS (CAV))

Propuestas CCEE

Florence Directo

Interconsultas

Florence Gestión

Emergency Activity

Hospital

Emergency Distribution

Hospital/ Primary Care

Primary and Hospital Care integration

Primary Care Hospital

Source: Ribera Salud

Demand ManagementResults

Source: Ribera Salud. Data from Vinalopó Hospital

Number of PC referrals to specialties related to the orthopedic and trauma service

Referrals (left axis)

Inter consultations (right axis)

Evolution of orthopedic and trauma surgery activity (1st consultations)

Vinalopó Hospital

Demand ManagementResults

TRAUMA

REHABILITATION

RHEUMATOLOGY

Demand ManagementResults

Referrals from PC to specialities.Utilization rate per 1,000 inhabitants

Vinalopó Hospital

Waiting listsResults

Source: Conselleria de Sanitat (Alumbra 2014). National Benchmark: Indicadores Clave del SNS: INCLASS 2015”

52 39 32 32

CV66

SNS90

0

10

20

30

40

50

60

70

80

90

100

Alzira Torrevieja Denia Vinalopó

Lista de espera quirúrgica (días de espera)

18 31 28 29

CV41

SNS53

0

10

20

30

40

50

60

Alzira Torrevieja Denia Vinalopó

Lista de espera consultas especialista (días de espera)Surgical waiting list in 2014 (in days) Specialized waiting list in 2014 (in days)

ComplexityResults

Number of bypasses. Source: BMSD of 29 hospitals. Elaborated by IASIST.

Average complexity (DRG) per age group

Number of bypasses

0,00

0,50

1,00

1,50

2,00

2,50

3,00

0-4 AÑOS 5-14 AÑOS 15-44 AÑOS 45-64 AÑOS 65-74 AÑOS <75 AÑOS

Complejidad media (peso GRD) global y por grupo de edad

Alzira; 1,66

Torrevieja; 1,86

Denia; 1,78

Vinalopo; 2,03

España; 1,74

1,50

1,60

1,70

1,80

1,90

2,00

2,10

1

Peso medio por hospital

Average weight (in red RS concessions, in black Spanish benchmark) per age group. Source: RS MBDS, Spanish

benchmark from DRG Ministry of Health 2013 database.

50 100 150

0 20 40 60 80 100 120 140 160 180 200 220

Número de Bypass

Mortality in Bypass and Valve Surgery 2014.Source: BMSD of 29 hospitals. Elaborated by IASIST

Gross and adjusted mortality rate

Gross mortality rate (left axis)

Adjusted mortality rate (right axis)

Valve surgery

Satisfaction Survey

8,6

8,6

8,7

9,0

CV 8,5

0 2 4 6 8 10

Alzira

Torrevieja

Denia

Vinalopó

7,8

7,8

7,7

8,0

CV 7,8

0 2 4 6 8 10

Alzira

Torrevieja

Denia

Vinalopó

Satisfacción global en la atención hospitalaria 2014 Satisfacción global en la atención primaria 2014

8,6

8,6

8,7

9,0

CV 8,5

0 2 4 6 8 10

Alzira

Torrevieja

Denia

Vinalopó

7,8

7,8

7,7

8,0

CV 7,8

0 2 4 6 8 10

Alzira

Torrevieja

Denia

Vinalopó

Satisfacción global en la atención hospitalaria 2014 Satisfacción global en la atención primaria 2014 Global satisfaction in Hospital care in 2014Global satisfaction in Primary care in 2014

Source: Conselleria de Sanitat 2014

Chronic Patient PlanResults

Fuente: Brookings “Spain: Global Accountable Care in Action”

91% of the patients show their satisfaction withthe health care provided.

94% do not know the Alzira Model.

Satisfaction Survey

Work Environment Survey

93% of our employees recommend Ribera Salud centers as a place to work in.84% consider that the organization provides the required information to do their job inoptimal conditions.The pride in belonging to this Group is the most highly rated indicator. 8 out of 10employees are satisfied or highly satisfied.What our employees consider the most important aspects in our Organization is:

• Career development• Respect and courtesy to the patient• Good working atmosphere• Ackknowlegement of the work carried out

All surveys “Best Place to Work” (credibility, respect, impartiality, pride and fellowship) show that our indicators are over the average in healthcare sector. 90% of our employees consider they are contributing in a positive way to the societywelfare, 6 points over the average in the healthcare sector.

Posición ,,, 8,00 4 5 10 6

Valor … 81,16 84,22 82,91 80,10 82,86RIBERA TORREVIEJA DENIA MANISES VINALOPÓ

Valor Valor Valor Valor Valor

1. Índice sintético de satisfacción. Calidad 97,58% 98,45% 98,85% 94,49% 92,67%

2. Índice de calidad de la información. Calidad 97,05% 95,10% 95,75% 95,23% 89,57%

3. Índice de percepción de mejora. Calidad 86,97% 93,09% 100,00% 89,00% 96,11%

Penalización OE.3- Ciudadanos: Generar confianza y seguridad en el sistema Penalizaciones

4. Indicador de Cobertura vacunal de polio a los 6 meses. Salud Pública 100,00% 94,48% 100,00% 99,06% 97,23%

5. Indicador de Cobertura vacunal de Triple Vírica a los 15 meses. Salud Pública 100,00% 93,49% 100,00% 100,00% 100,00%

6. Indicador de Cobertura vacunal DTP a los 18 meses. Salud Pública 92,59% 80,09% 92,13% 92,28% 91,82%

7. Cribado de HTA de riesgo elevado Salud Pública 30,67% 39,81% 30,46% 33,04% 34,41%

8. Control de hipertensión Salud Pública 25,44% 39,84% 25,17% 27,84% 33,23%

9. Indicador de Cribado de diabetes. Salud Pública 65,60% 62,94% 45,15% 70,47% 55,82%

10. Control de diabetes Salud Pública 34,91% 48,62% 30,91% 35,75% 33,03%

11. Calidad en el Seguimiento del Embarazo en Atención Primaria. Salud Pública 97,17% 93,52% 95,19% 96,47% 95,81%

12. Niños con examen de salud completo en SIA por Atención Primaria. Salud Pública 81,59% 77,28% 71,01% 80,02% 86,19%

13. Valoración del riesgo vascular Seguridad 1,17% 4,84% 0,07% 1,86% 4,11%

14. Indicador de abandono tabáquico en pacientes de alto riesgo Salud Pública 3,31% 4,09% 1,56% 3,01% 4,00%

15. Indicador de registro del Índice de Masa Corporal Salud Pública 38,24% 44,23% 33,86% 38,95% 44,75%

16. Pacientes con diagnóstico correcto de EPOC Seguridad

17. Seguimiento del puerperio Registro AP

18. Indicador de cobertura vacunal del VPH Salud Pública 72,12% 43,23% 44,49% 69,35% 71,17%

19. Indicador de cobertura vacunal del virus de la gripe Salud Pública 65,73% 38,75% 47,18% 49,66% 59,95%

20. Cribado de tabaquismo Salud Pública 2,11% 5,09% 0,84% 2,28% 6,81%

Penalización OE.3- Promover la salud - Vacunaciones Penalizaciones

Penalización OE.3- Promover la salud - Niño y embarazo Penalizaciones

Satisfacción: Prestar atención sanitaria que responda a las expectativas de la población.

Ciudadanos: Generar confianza y seguridad en el sistema.

Ciudadanos: Generar confianza y seguridad en el sistema.

Promover la salud

COMPARATIVA CONCESIONES 2011

INDICADOR Tema

Prestar atención sanitaria que responda a las expectativas de la población.

Posición ,,, 8,00 4 5 10 6

Valor … 81,16 84,22 82,91 80,10 82,86RIBERA TORREVIEJA DENIA MANISES VINALOPÓ

Valor Valor Valor Valor Valor

1. Índice sintético de satisfacción. Calidad 97,58% 98,45% 98,85% 94,49% 92,67%

2. Índice de calidad de la información. Calidad 97,05% 95,10% 95,75% 95,23% 89,57%

3. Índice de percepción de mejora. Calidad 86,97% 93,09% 100,00% 89,00% 96,11%

Penalización OE.3- Ciudadanos: Generar confianza y seguridad en el sistema Penalizaciones

4. Indicador de Cobertura vacunal de polio a los 6 meses. Salud Pública 100,00% 94,48% 100,00% 99,06% 97,23%

5. Indicador de Cobertura vacunal de Triple Vírica a los 15 meses. Salud Pública 100,00% 93,49% 100,00% 100,00% 100,00%

6. Indicador de Cobertura vacunal DTP a los 18 meses. Salud Pública 92,59% 80,09% 92,13% 92,28% 91,82%

7. Cribado de HTA de riesgo elevado Salud Pública 30,67% 39,81% 30,46% 33,04% 34,41%

8. Control de hipertensión Salud Pública 25,44% 39,84% 25,17% 27,84% 33,23%

9. Indicador de Cribado de diabetes. Salud Pública 65,60% 62,94% 45,15% 70,47% 55,82%

10. Control de diabetes Salud Pública 34,91% 48,62% 30,91% 35,75% 33,03%

11. Calidad en el Seguimiento del Embarazo en Atención Primaria. Salud Pública 97,17% 93,52% 95,19% 96,47% 95,81%

12. Niños con examen de salud completo en SIA por Atención Primaria. Salud Pública 81,59% 77,28% 71,01% 80,02% 86,19%

13. Valoración del riesgo vascular Seguridad 1,17% 4,84% 0,07% 1,86% 4,11%

14. Indicador de abandono tabáquico en pacientes de alto riesgo Salud Pública 3,31% 4,09% 1,56% 3,01% 4,00%

15. Indicador de registro del Índice de Masa Corporal Salud Pública 38,24% 44,23% 33,86% 38,95% 44,75%

16. Pacientes con diagnóstico correcto de EPOC Seguridad

17. Seguimiento del puerperio Registro AP

18. Indicador de cobertura vacunal del VPH Salud Pública 72,12% 43,23% 44,49% 69,35% 71,17%

19. Indicador de cobertura vacunal del virus de la gripe Salud Pública 65,73% 38,75% 47,18% 49,66% 59,95%

20. Cribado de tabaquismo Salud Pública 2,11% 5,09% 0,84% 2,28% 6,81%

Penalización OE.3- Promover la salud - Vacunaciones Penalizaciones

Penalización OE.3- Promover la salud - Niño y embarazo Penalizaciones

Satisfacción: Prestar atención sanitaria que responda a las expectativas de la población.

Ciudadanos: Generar confianza y seguridad en el sistema.

Ciudadanos: Generar confianza y seguridad en el sistema.

Promover la salud

COMPARATIVA CONCESIONES 2011

INDICADOR Tema

Prestar atención sanitaria que responda a las expectativas de la población.

Health Department Evaluation

About RIBERA SALUD

What We Do

More than…

1,500 scientific publications and 600 research projects

100 National and International Awards

350 National and International Conferences (World Bank, BID etc…)

6,000 professionals

500 doctors trained

3,000 Healthy Activities (Promotion Plans)

700 Million € committed investment

30 Quality Certifications

And…

Visits from more than 100 countries (Governments, Universities, Institutions)

Leading a Process of Change

RIBERA SALUD…

Is the only Spanish Company exclusively dedicated to the Administrative Concessions in healthcare sector.

Torrevieja Hospital developed FLORENCE (electronic clinical history), which was implemented in 15 Hospitals in Chile.

Torrevieja and Vinalopó Hospitals have implemented a shared services system to foster the multi-hospital vision.

Has implemented an interactive health portal Patients/professionals.

First project of patients segmentation according to the risk level.

Alzira Model…

Is the first project with a per capita finance system, whose objective is the health promotion.

Establishment of Integrated Healthcare Centers (CSI), joining Primary Care and technology to Specialized Care.

Is the first PPP considered as a case study by Harvard University.

Alzira Hospital, first public hospital…

In Spain with electronic clinical history and digital radiology (1997).

In Spain with individual rooms and a bed for the companion (1997).

That developed an integration model Hospital /Primary Care.

Committed to CSR Alzira Hospital, first public hospital in Spain with sign Language Interpreter (1997).

The Expansion of the Alzira Model

Where we are

“Florence” software in 15 public hospitals

in Chile, 3 in Uruguay and 2 clinics in

Honduras

In Spain In Latin America

Where we are

Hospital del Vinalopó Elche-Alicante

www.riberasalud.comwww.albertoderosa.comwww.modeloalzira.com

@riberasalud