Implementation of clinical pathways in primary care

Development of integrated clinical pathways, that include primary care before and after hospitalisation, was one of the main goals when the government launched the Care Coordination Reform in Norway in 2012. In the new legislation, hospitals and local health authorities are required by law to make binding co-operation agreements that coordinate transition of patients both in and out of hospitals. We have followed some hospitals and adjacent local health authorities that have collaborated in the development and implementation of clinical pathways that include follow-up in primary care. We find that specialisation of services and personnel needed for diagnosis specific pathways was neither sustainable nor functional. Prolonging diagnosis specific pathways into primary care can also lead to more fragmented services for persons with multiple chronic conditions. Still, some local health authorities developed a generic (not diagnosis specific) pathway that appears to be a more sustainable model.

Keywords: Integrated care, care coordination, patient-centred care, home health care nursing, multimorbidity

The new Health and Care Services Act from 2012 commits municipalities and health enterprises to sign a cooperation contract. The contracts aim to promote collaboration between municipalities and health enterprises by stating the distribution of tasks and responsibilities and establishing good local collaboration practices. In this paper, we explore the extent to which the introduction of these contracts affects levels of conflicts and perceived collaboration between municipalities and health enterprises with regard to patient discharge practices between levels of care. Data sources include cases reported to and decisions made by the National Committee for Dispute Resolution for the Health and Care Sector; a survey among key-persons from all health enterprises; and interviews with informants from four case-municipalities. By the end of 2015, the National Committee had received 17 cases. Most of the cases involved patient discharge. Survey- and interview data indicated that conflicts or disagreements that are not presented to the National Committee concerned patient discharge as well. Informants from the case-municipalities reported the increased speed in the transfer of patients between services and sectors to be their main challenge. The results seem to indicate that the introduction of cooperation contracts has not contributed to reduce tensions and conflicts. It remains uncertain if conflicts would have been more frequent and severe without such contracts. Overall, the findings in this paper underlined that cooperation contracts may constitute a useful framework for coordination between hospitals and municipalities, but cannot replace the day-to-day dialogue in discharging patients from hospital to municipal care services.

Keywords: Coordination reform, Health enterprises, Local health and careservices, Cooperation Agreements

The role of regular general practitioners in The Coordination Reform – a distance relationship?

Expectations for regular General practitioners (GPs) stronger horizontal and vertical integration in The Norwegian Coordination Reform is relatively clear. Given three different perspectives, the article analyzes whether these expectations are met. The policy perspective, which is based on analysis of policy documents and changes in GPs regulation, shows that the reform has barely challenged GPs autonomous role in the municipality. The new service agreement system contains neither good structures nor mechanisms to ensure vertical and horizontal integration. The municipal perspective, supported by qualitative and quantitative data from municipalities, shows that it is difficult for the municipality to control GPs via service agreements and regulations. The respondents in our material show much willingness and interest to collaborate with GPs in line with the reform ambitions. At the same time they expresse disappointment over GPs lack of engagement, and it seems largely to be accepted that GPs’ are “outside” the municipal health care system. The GP perspective, where we have analyzed data from GPs, matches the image of the GP’s role with a certain distance to instruments in the reform.

Keywords: General practitioners, The Coordination Reform, primary care, integrated care

Regular general practitioners (GPs) perform an essential part of diagnosis and treatment in primary health care in Norway. There are no measures in the coordination reform aimed directly towards GPs. The article describes by means of regression analyses the use of GP services and specialist services during the period 2009-2014 for patients with diagnosed chronic illnesses and a comparison group. We do not find a shift in the distribution between the two types of services after the coordination reform was introduced from 1 January 2012.

Keywords: Chronic diseases, primary health care, specialist health care

Intermunicipal cooperation in Norwegian healthcare: Is the «healthcare municipality» taking shape?

As of 2016, all Norwegian municipalities are obliged to provide 24-hour acute services to their citizens (municipal acute bed units – MAUs). These services can be provided in cooperation with other municipalities or alone. In this article, we focus on intermunicipal cooperation on MAUs and out-of-hours services and the degree to which these intermunicipal cooperation arrangements overlap. The analysis is based on complete data on the organisation of both services. Our results show that intermunicipal cooperation is widespread for both services and that overlap is common. We also find that both the likelihood of cooperating and the likelihood of being part of an overlapping network are related to the municipality’s geographical proximity to a hospital. In the concluding part of the article, we relate our findings to theoretical questions based on strong or weak ties in networks. We also ask what the implications of our findings may be for municipal structure and local governance.

Keywords: Coordination Reform, municipal health service, community hospitals, out-of-hours services, municipal organization, transaction costs

The aim of the introduction of the municipal emergency care units (MEUs) was to reduce hospitalizations, particularly for the elderly. We analyzed whether implementation of MEUs had the desired effect. Data on hospitalizations was acquired from the Norwegian patient register and data on demographic variables and municipal health and care services were acquired from Statistics Norway. We collected data about when MEU implementation occurred from the municipalities. Data were analyzed as a panel with fixed effects for municipalities. The conclusions are that the introduction of MEUs had the intended effects, but that the effects varied significantly depending upon how MEUs were organized. On average, the association between the implementation of the MEUs and hospitalizations for patients over 80 years was barely (minus) 2%. MEUs that affected hospitalization rates were those co-located with outpatient emergency services or those which had a physician on duty 24/7. Other types of organizational structure had no effects on average. The effects of the implementation of MEUs were significant only for municipalities with more than 5000 inhabitants.

Keywords: Municipalities, local emergency services, hospital admissions

Evaluation of health care reform: the introduction of municipal copayment

As part of the Norwegian Coordination Reform of 2012, municipal co-payment of general hospital admissions was introduced. The co-payment was implemented for medical specialist services whereas surgical treatment was exempted. We investigate whether municipal co-payment did have effects on the use of specialized health care services. The hypothesis is that when a municipality must contribute to payment for the treatment of patients from the municipality, they will implement measures to reduce the use of the relevant specialist health care services. Data include individual level information on the entire population of Norway for the period 2010-2013. In addition to the use of specialist somatic health care services, we include information on consultations with private specialists, general practitioners and physiotherapists, as well as individual level patient characteristics. Data are collected from different registers at Statistics Norway. We analyse whether the probability of visits to somatic treatment hospitals has changed due to the reform. Analyses based on descriptive statistics and regression analyses give no indications that use of specialist somatic health care services have changed as a result of municipal co-payment of these services.

Keywords: The Coordination Reform, Reform Evaluation, use of specialist health care, payment for treatment

The Cooperation Reform, implemented from 1st January 2012, included among other things a municipal daily fee for patients staying in hospitals following the day they were defined as ready for discharge. The research questions are whether implementing the fee was associated with reduction in length of stay and increased acute 30 days readmissions rates for the relevant patient groups. The results indicate that the implementation of the Cooperation Reform was associated with a reduction of length of stay of 0.1 day. We analyzed four patient groups in details; patients with hip fracture, stroke, heart failure and COPD. For patients classified as ready for discharge and consequently were in need of municipal services, the observed reductions were larger, for example 4–6 days for patients hospitalized with stroke or hip fracture. Readmission rates increased with age and comorbidities. Patents classified as ready for discharge had higher readmission rates than those that were not. There was an increase in readmission rates of 1–2 percentages in the period we analyzed but there were no significant changes in readmission rates that were associated with the implementation of the Cooperation reform for any of the analyzed groups. There were however differences both between health enterprises and municipalities. Our interpretation is that the municipalities generally managed to handle the increased care burden that followed from the Cooperation Reform.

Keywords: Patients ready for discharge, municipality, hospital

For elderly patients, good coordination of care is particularly important, since they often need health care and care services at different administrative levels. In cases where the elder’s own resources are insufficient, because of poor health and often weakened cognitive ability, the resources of relatives (spouse or children) are potentially important. The Norwegian Care Coordination reform, introduced in 2012, may have altered the role of spouse and off-spring. On the one hand, the reform is intended to improve coordination and strengthen formal care at the primary care level, on the other hand, reform effects such as shorter hospital length of stay may increase the demand for informal care. In this analysis, we investigate the relationship between family resources and mortality and hospital readmission for patients aged 70 and above who have had an emergency hospital admission. The analysis benefits from data from The Norwegian Patient Register, merged with data from Statistics Norway and KOSTRA. Our results show that having a spouse and/or an adult child is negatively associated with mortality and positively associated with being readmitted to hospital within 30 days. The analysis does not indicate that the Care Coordination reform has altered the relationship between family resources and mortality or readmission.

Keywords: Mortality, readmission, elderly, informal care, Care Coordination reform.