Problem: Observed health inequalities in vulnerable populations; higher costs linked to overrepresentation of vulnerable populations enrolled in Clalit Health Services.
Solution highlights: Creation of a composite disparity score allowed health disparities in Clalit Health Services to be identified, assessed and then targeted for intervention; top-down leadership from senior management within Clalit Health Services was essential for creating the conditions needed for change; locally-designed initiatives provided tailored solutions for achieving targets set by senior management; capitalizing on preexisting strengths and resources minimized the need for costly investments; data-driven performance measures were the backbone of the initiative and provided evidence of the need for intervention, helped incentivize performance improvements and allowed monitoring and evaluation of progress; regular feedback and monitoring fostered a culture of continuous learning and evidence-based performance improvement.
Description of practice
With 4.2 million enrolees, Clalit Health Services is the largest of four health funds in Israel and provides coverage to over half the population. As government funding is awarded on a capitation basis and Clalit acts as both the insurer and provider of services, Clalit has a financial interest in supporting enrolee health. Large differences in life expectancy, infant mortality and chronic disease relating to geographic area, minority status and education level have been observed across Israel. With an overrepresentation of vulnerable groups, supporting good health for all enrolees is particularly important for Clalit Health Services.
Capitalizing on an organization-wide electronic medical records system, Clalit developed a data-driven initiative to improve performance in clinics where the widest health disparities were observed. An expert steering committee was assembled to examine and rank 70 quality indicators routinely collected by Clalit according to level of disparity between high and low socioeconomic populations. Seven indicators measuring both performance and health outcomes were selected to form a composite health disparity score (QUIDS). Clalit clinics in all districts were then ranked by QUIDS and those with the highest disparity were designated as targets for intervention; 55 clinics (approximately 10%) were selected. District leaders were then convened at a conference to review QUIDS rankings, provided with guidance on addressing observed disparities and assigned performance targets. Financial incentives were put in place to support achievement of goals, with incentives applied at the district level to foster team-working and collaboration between all clinics in each district. While no disincentives were applied, strong accountability chains created enough managerial pressure through inherent competition to motivate performance improvements. Through bottom-up initiatives, local districts and clinics planned and implemented tailored interventions designed to reduce disparities. Interventions included strengthening leadership skills of clinic staff, extending clinic hours, increasing community services, improving cultural competencies, engaging community leaders and targeting outreach to at-risk patients.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
Top-down leadership at the senior management level within Clalit Health Services drove development and implementation of the disparity reduction strategy by establishing the necessary conditions and priorities for performance improvements. Top-down leadership was, however, coupled with a bottom-up approach and district leaders were empowered to implement locally-tailored interventions, with primary care providers acting as the main implementers of change. Primary care providers’ commitment to improvement was largely driven by a sense of accountability for population health deriving from cradle-to-grave relationships with patients. Providers showed dedication to improving patient health and flexibility in their willingness to adapt practices to better meet patients’ needs.
Feedback on QUIDS focused attention on decreasing disparity rather than simply generating overall improvements. All 55 target clinics showed improvements on QUIDS post-intervention and inequality gaps between target and non-target clinics narrowed by approximately 60% within three years. Greatest improvements were seen in performance-based quality indicators (performance of blood tests, influenza vaccination and mammography exams). Outcome-based indicators (diabetes, blood pressure and lipid control and infant anaemia) were more modest, but still exceeded those seen in non-target clinics. Clalit continues to monitor progress and an evaluation is underway to provide insight into how improvements were accomplished.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Ran Balicer
- Clalit Health Services