Conducting a Health Needs Assessment to Identify Potentials for Population-based Integrated Care Models in Socially Deprived Urban Regions – The Example of the Integrated Care Project “Billstedt-Horn” in Hamburg, Germany

Introduction: Against the background of regional differences in morbidity and social determinants of health small-scale health services research is becoming increasingly relevant, particularly for planners of population-based integrated care models. Despite of longstanding research of regional variation especially by John Wennberg neither are there scientifically or practically accepted standards on how to identify regions which are in a special need for integrating health services nor is there a precisely defined set of methods which could be used to identify and prioritize problems in health services delivery.

Policy context and objective: Based on discussions with the health authority of Hamburg the two neighbouring districts of Billstedt and Horn were predefined as a potential region for integrated care activities due to their comparable situation in terms of social deprivation as indicated by several social and demographical indicators. Having focussed on this region the health-related characteristics should be systematically analysed in more detail to develop a comprehensive concept of intervention. Therefore quantitative data analysis of several data sources (statutory health insurance claims data, data of the local health authority, reports of statistical offices and urban planning) as well as qualitative interviews with regional providers were conducted to better understand the health needs of the population living in this area and problems in the way healthcare is provided.

Targeted population: The population living in Billstedt or Horn is socially disadvantaged compared to the general population in Hamburg as well as in Germany overall. For example higher unemployment rates, a higher amount of unskilled workers and lower average incomes can be observed which among other indicators is the cause of very low status indexes of these districts [1]. People living in Billstedt or Horn are indeed about four years younger than the population in Hamburg but the older they get the more health related problems they have compared to the average [2].

Highlights: Calculating mean ages at the time of death and comparing residents living near chosen subway stations showed mean ages between 71 to 74 for the stations in Billstedt and Horn and for example mean ages between 82 to 87 in socially much more advantaged regions in Hamburg. The claims data analysis moreover indicates that several chronic morbidities like e.g. backpain, depression and diseases of the coronary system occur five to ten years earlier in Billstedt and Horn than averagely in Hamburg. For the region of Billstedt and Horn four key areas for potential interventions were proposed based on the claims data analyses: 1. Improving care for multimorbid elderly patients, 2. Prevention of the metabolic syndrome, 3. Better access to psychiatric care and 4. Improving child health. The qualitative interviews furthermore highlighted problems of unnecessary utilization like e.g. preventable hospital cases which occur due to existing or expected speech barriers in ambulatory care respectively a general unconsciousness of adequate ambulatory health institutions or problems of access to specialist care due to an observable unwillingness of several providers to open a practice in this region which is even exacerbated by a unwillingness of a certain amount of resident patients to leave their district to use health services. The establishment of a multilingual “retail clinic” in a large mall in Billstedt led by a nurse practitioner or a physician assistant who is in charge of offering care coordination consulting was proposed subsequently.

Transferability: The methodology of this mixed-methods health services research as a starting point could be used in other settings where an integrated care model is planned. The identified problem fields and the thereupon developed intervention strategies might guide integrated care managers or policy makers on how to systematically plan, implement and/or further develop integrated care systems.

Conclusions: The analysis of the regional social and health characteristics enabled the preparation of a comprehensive concept of planned integrated care strategies and first specific interventions. Because of the systematic approach several providers and health insurances finally could be convinced to participate in a proposal to the German Ministry of Health to give a start up funding for this integrated care project in course of a so called “innovation fund”. The proposal was finally chosen to be granted with the funding amount of about 6.3 million Euros over three years starting in 2017.

1- Pohlan, J./Dafateri-Moghaddam, N. Sozialmonitoring Integrierte Stadtteilentwicklung. Bericht 2012. Hamburg: HafenCity Univiversity Department Stadtplanung Stadt- und Regionalökonomie. 2015

2- Erhart, M./Hering, R./Schulz, M./Graf von Stillfried, D. Morbiditätsatlas Hamburg. Berlin: Zentralinstitut für die kassenärztliche Versorgung in Deutschland. 2013