Work like a Doc: a comparison of regulations on residents' working hours in 14 high-income countries

Background: Medical residents work long, continuous hours. Working in conditions of extreme fatigue has adverse effects on the quality and safety of care, and on residents' quality of life. Many countries have attempted to regulate residents’ work hours. Objectives: We aimed to review residents’ work hours regulations in different countries with an emphasis on night shifts. Methods: Standardized qualitative data on residents’ working hours were collected with the assistance of experts from 14 high-income countries through a questionnaire. An international comparative analysis was performed. Results: All countries reviewed limit the weekly working hours; North-American countries limit to 60–80 h, European countries limit to 48 h. In most countries, residents work 24 or 26 consecutive hours, but the number of long overnight shifts varies, ranging from two to ten. Many European countries face difficulties in complying with the weekly hour limit and allow opt-out contracts to exceed it. Conclusions: In the countries analyzed, residents still work long hours. Attempts to limit the shift length or the weekly working hours resulted in modest improvements in residents’ quality of life with mixed effects on quality of care and residents’ education

Wie können Finanzierungsmethoden die Versorgung von Menschen mit Multimorbidität in Europa verbessern?

Payment mechanisms that take multiple chronic conditions into account and actually promote better integration of care are sadly lacking. This policy brief examines the steps policy makers must take if they are to adapt financing systems to support people with multimorbidity better. It looks at securing sustainable funding; options for upgrading payment mechanisms; and how financing mechanisms can stimulate good quality integrated care for people with multimorbidity. Key messages include that: * Payment mechanisms can provide key incentives for providers to collaborate, enable better care and create efficiency savings (while paying individual providers separately tends to block integration). * Innovative payment mechanisms (shared savings models, bundled payments, pay for performance) can be combined with more traditional models (budget, capitation, fee for service) but are inevitably complex. They need to adequately account for the complexity of cases treated which means drawing on very extensive data on cost and quality and considerable technical expertise. * Policy makers, who are working to make financing support integrated care, need to give a strong leadership signal and create supportive national and programme structures. They must: - Put in place information and support systems to deal with the complexity - Give proper thought to local conditions (and local capacity to cope) - Consider funding guarantees and other strategies for mainstreaming new approaches so that providers are encouraged to innovate, and - Take an incremental and long-term approach to change (including ongoing evaluation).EU, ICARE4EU, Innovating care for people with multiple chronic conditions in Europ

Integrated Diabetes Care Delivered by Patients – A Case Study from Bulgaria

Introduction: Increasing numbers of persons are living with multiple chronic diseases and unmet medical needs in Bulgaria. The Bulgarian ‘Diabetic care’ non-profit (DCNPO) programme aims to provide comprehensive integrated care focusing on people with diabetes and their co-morbidities. Methods: The DCNPO programme was selected as one of eight ‘high potential’ programmes in the Innovating Care for People with Multiple Chronic Conditions (ICARE4EU) project, covering 31 European countries. Data was first gathered with a questionnaire after which semi-structured interviews with project staff and participants were conducted during a site visit. Results: The programme trains diabetic patients to act as carers, case managers, self-management trainers and health system navigators for diabetic patients and their family. The programme improved care coordination and patient-centered care by offering free care delivered by a multidisciplinary team. It facilitates the collaboration between patients, volunteers, health providers and the community. Internal evaluations demonstrate reduced hospital admissions and avoidable amputations, with consequent cost savings for the health care system. Conclusion: Integrated care provided by volunteering patients can empower people suffering from diabetes and their co-morbidities and address health and social inequalities in resource-poor settings. It can also contribute to an increased trust and improved satisfaction among vulnerable patients with complex care needs

Anreize zur Integration: Eine Typologie von Vergütungsmethoden für die integrierte Versorgung.

Traditional provider payment mechanisms may not create appropriate incentives for integrating care. Alternative payment mechanisms, such as bundled payments, have been introduced without uniform definitions, and existing payment typologies are not suitable for describing them. We use a systematic review combined with example integrated care programmes identified from practice in the Horizon2020 SELFIE project to inform a new typology of payment mechanisms for integrated care. The typology describes payments in terms of the scope of payment (Target population, Time, Sectors), the participation of providers (Provider coverage, Financial pooling/sharing), and the single provider/patient involvement (Income, Multiple disease/needs focus, and Quality measurement). There is a gap between rhetoric on the need for new payment mechanisms and those implemented in practice. Current payments for integrated care are mostly sector- and disease-specific, with questionable impact on those with the most need for integrated care. The typology provides a basis to improve financial incentives supporting more effective and efficient integrated care systems.EC/H2020/634288/EU/Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE/SELFI

Towards incentivising integration: A typology of payments for integrated care

Traditional provider payment mechanisms may not create appropriate incentives for integrating care. Alternative payment mechanisms, such as bundled payments, have been introduced without uniform definitions, and existing payment typologies are no

Relevante Modelle und Elemente der integrierten Versorgung für die Multimorbidität: Ergebnisse eines Scoping-Reviews.

BACKGROUND: In order to provide adequate care for the growing group of persons with multi-morbidity, innovative integrated care programmes are appearing. The aims of the current scoping review were to i) identify relevant models and elements of integrated care for multi-morbidity and ii) to subsequently identify which of these models and elements are applied in integrated care programmes for multi-morbidity. METHODS: A scoping review was conducted in the following scientific databases: Cochrane, Embase, PubMed, PsycInfo, Scopus, Sociological Abstracts, Social Services Abstracts, and Web of Science. A search strategy encompassing a) models, elements and programmes, b) integrated care, and c) multi-morbidity was used to identify both models and elements (aim 1) and implemented programmes of integrated care for multi-morbidity (aim 2). Data extraction was done by two independent reviewers. Besides general information on publications (e.g. publication year, geographical region, study design, and target group), data was extracted on models and elements that publications refer to, as well as which models and elements are applied in recently implemented programmes in the EU and US. RESULTS: In the review 11,641 articles were identified. After title and abstract screening, 272 articles remained. Full text screening resulted in the inclusion of 92 articles on models and elements, and 50 articles on programmes, of which 16 were unique programmes in the EU (n=11) and US (n=5). Wagner's Chronic Care Model (CCM) and the Guided Care Model (GCM) were most often referred to (CCM n=31; GCM n=6); the majority of the other models found were only referred to once (aim 1). Both the CCM and GCM focus on integrated care in general and do not explicitly focus on multi-morbidity. Identified elements of integrated care were clustered according to the WHO health system building blocks. Most elements pertained to 'service delivery'. Across all components, the five elements referred to most often are person-centred care, holistic or needs assessment, integration and coordination of care services and/or professionals, collaboration, and self-management (aim 1). Most (n=10) of the 16 identified implemented programmes for multi-morbidity referred to the CCM (aim 2). Of all identified programmes, the elements most often included were self-management, comprehensive assessment, interdisciplinary care or collaboration, person-centred care and electronic information system (aim 2). CONCLUSION: Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.EC/H2020/634288/EU/Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE/SELFI

The SELFIE Framework for Integrated Care for Multi-Morbidity

There is an increasing prevalence of multi-morbidity, which is associated with lower quality of life and higher expenditures, and constitutes a challenge to current, often fragmented, care provision. Integrated care programmes appear to be a promising solution. However, the dialogue on such programmes needs to be streamlined to ensure continuation, wider implementation and sustainable financing. The SELFIE framework provides a means to ensure such a dialogue by structuring relevant concepts of integrated care for multi-morbidity. The framework can be used to describe, develop, implement and evaluate integrated care programmes for multi-morbidity

The SELFIE framework for integrated care for multi-morbidity: development and description

Background The rise of multi-morbidity constitutes a serious challenge in health and social care organisation that requires a shift from disease- towards person-centred integrated care. The aim of the current study was to develop a conceptual framework that can aid the development, implementation, description, and evaluation of integrated care programmes for multi-morbidity. Methods A scoping review and expert discussions were used to identify and structure concepts for integrated care for multi-morbidity. A search of scientific and grey literature was conducted. Discussion meetings were organised within the SELFIE research project with representatives of five stakeholder groups (5Ps): patients, partners, professionals, payers, and policy makers. Results In the scientific literature 11,641 publications were identified, 92 were included for data extraction. A draft framework was constructed that was adapted after discussion with SELFIE partners from 8 EU countries and 5P representatives. The core of the framework is the holistic understanding of the person with multi-morbidity in his or her environment. Around the core, concepts were grouped into adapted WHO components of health systems: service delivery, leadership & governance, workforce, financing, technologies & medical products, and information & research. Within each component micro, meso, and macro levels are distinguished. Conclusion The framework structures relevant concepts in integrated care for multi-morbidity and can be applied by different stakeholders to guide development, implementation, description, and evaluation.EC/H2020/634288/EU/Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE/SELFI

Neue Versorgungsformen. Ein Rahmen für gute Zusammenarbeit

Wenn Menschen mehrere chronische Krankheiten gleichzeitig haben, brauchen sie eine abgestimmte Behandlung. Wie Integrierte Versorgung für diese Patienten gelingen kann, beschreibt eine europäische Forschergruppe mithilfe des SELFIE Framework