Presentación de Bernardo Valdivieso, Director Planificación en Departamento de Salud Valencia LA FE.

1. Innovation in care for chronic conditions
Integrated Care
Valencia Reference Site ***
Dr. Bernardo Valdivieso
valdivieso_ber@gva.es

2. - Introduction
- Good practice
- Scaling up
Overview
2

3. An introduction to the Valencia region

4. An introduction to Department LA FE
4
•Population: 300.000
– > 65 years old: 17,3%
– 9 Health Areas
•Health System
– Hospital for tertiary care: 1
– Hospital for chronic patients:1
– Primary Care Centers: 18
•Human resources
– Hospital: 6.800
– Primary Care: 350
•Activity:
• 35 % basic; 65% reference
•Budget: 600 M€

5. An introduction to Department LA FE
• Integrated Health Care Organization
• Unique Management System
• Alternatives to traditional hospitalization
• Health Information System. “Level 6 Emram scale”

6. Triple Aim

7. Transforming The Model

9. - Introduction
- Good practice
- Scaling up
Summary
9

10. Disease management:
Patients with medium level of need
• Moderately-complex chronic conditions
Supported self care
Patients with low level of need
•Low-complex chronic conditions
ProfessionalCareProfessionalCare
80%
5 %
15%
Case management
Patients who need a intensive level of attention
•Highly-complex chronic conditions
•End of life conditions
Innovation in care for chronic conditions
10

11. C.Inclusion
Case management
Phone-visits
Doubts & alerts
Coordination
Geriatric assessment
Care Plan
Intensive Education
Ambulatory CareHome Care IB <30
Hospital at Hone
Hospitalisation
Hospitalisation
Complex
Ambulatory
Care
Complex
Hospitalisation
LONG–MEDCARE
Inclusión
Care
Professional
Self-CarePatient
Caregiver Self- Control
Transition
Care
Adapting care processes. "Case Management"

12. Patients
included
Randomization
Branch A
Control Group
198 patients
Branch A
Control Group
198 patients
Branch B
Case Management
198 patients
Branch B
Case Management
198 patients
Branch C
Case Management
Technology Nomhad
99 patients
Branch C
Case Management
Technology Nomhad
99 patients
No
intervention
No
intervention
InterventionIntervention InterventionIntervention
Process
analysis
Process
analysis SatisfactionSatisfaction
Respources
consumption
Respources
consumption
SecuritySecurity
Intervention
Cost
Intervention
Cost
MortalityMortality
Intervention
Cost
Health-
related
Quality of
Life
Assessment. Clinical Trial
12

13. Assessment. Clinical Trial

14. Usual Care Integrated Care
Patient call every three weeks during working hours
(8-15h)
Patient Call every 15 days and 24/7 covered
Patient social evaluation during hospital stay and
during inclusion in CMP
Patient social evaluation during inclusion, and every 4
months in new care model . Closer follow-up
Physiological measurement when patients
receives/goes GP visits
Physiological measurement sent by patient every
week through PC tablet
Educational intervention during inclusion in CMP
Educational Intervention at the inclusion and during
follow-up (trough PC tablet or presentially)
Transitions care from STC to LTC focused in clinical
care
Transitions care has both perspectives Clinical and
social

15. - Introduction
- Good practice
- Scaling up
Summary
15

16. Disease management:
Patients with medium level of need
• Moderately-complex chronic conditions
Supported self care
Patients with low level of need
•Low-complex chronic conditions
ProfessionalCareProfessionalCare
80%
5 %
15%
Case management
Patients who need a intensive level of attention
•Highly-complex chronic conditions
•End of life conditions
Scaling up 1/5
16
30% implemented30% implemented

17. Gestión de Enfermedad:
•Pacientes crónicos de complejidad moderada
• Monorgánicos
Autocuidados:
•Pacientes crónicos de baja complejidad
•Factores de riesgo
80%
5 %
15%
Gestión de Casos
•Pacientes crónicos de alta complejidad,
pluripatologicos”
•Pacientes en fase final de la vida
CuidadoProfesionalCuidadoProfesional
Scaling up 2/5

18. Scaling up 3/5
“Smart e-health platform”

19. “Real World Evidence”
Scaling up 4/5

20. Scaling up 5/5
“Real World Evidence”

22. Innovation in care for chronic conditions
Integrated Care
Valencia Reference Site ***
Dr. Bernardo Valdivieso
valdivieso_ber@gva.es