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A Strategy to Tackle the Challenge of Chronicity in the Basque Country


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Sufferers from chronic conditions tend to slip under the radar of the health system. this is …

Sufferers from chronic conditions tend to slip under the radar of the health system. this is
because for decades the system has been based upon the logic of rescue, of saving lives and
so, therefore, has focused on acute illnesses. faced with the increase in chronic illnesses it
is necessary to complement this system with one which deals in terms of caring as well as
curing, one which offers continuity of care throughout a person’s life, with the added potential
of preventing unnecessary hospitalizations and thus reducing costs.

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  • 1. A Strategyto Tackle theChallengeof Chronicityin the BasqueCountryJuly 2010
  • 2. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Foreword Sufferers from chronic conditions tend to slip under the radar of the health system. this is because for decades the system has been based upon the logic of rescue, of saving lives and so, therefore, has focused on acute illnesses. faced with the increase in chronic illnesses it is necessary to complement this system with one which deals in terms of caring as well as curing, one which offers continuity of care throughout a person’s life, with the added potential of preventing unnecessary hospitalizations and thus reducing costs. in the forthcoming two decades 26% of all Basques, the baby boomers, will belong to the over 65 age group. for the first time our society must prepare itself for a situation in which those who, today, are aged 50 will have to care for their parents for longer than they have looked after their children. Without major changes in our social policies and in the concept we have of ageing, it will be impossible to face up to the challenges of the current social panorama. this document proposes what is to be done and the steps to be taken in order to achieve just that in the Basque country. Medicine and bioscience will bring new discoveries in the decades to come. Many of these will save lives and will be fundamental for chronic patients. however, there are two other significant areas which will change: healthcare to the same degree as biomedical progress and which will also save a great number of lives and which will also be essential for chronic patients. i refer to the advance in information technologies and the organization of services. the Strategy described in this text values these advances equally to those of the progresses in biomedicine, pointing out that bioscience alone is not enough to face the challenge of chronicity in our societies. the way the health care system is organized at the provider level will become more and more important as we move forward. it should become as important as the treatments it provides. furthermore, in managerial terms, it will not be possible to improve the system by focusing only on the internal performance of care organizations. the improvement in coordination between them is even more important. Primary care, hospitals and social services are interdependent. it is necessary for them to find more collaborative and better coordinated approaches. it is in this collaboration in which advances are to be found for chronic patients and in which wide margins for efficiency improvements can be identified which will enable the sustainability of the health system. to this end, it will be necessary to cease to manage structures and to learn to manage integrated health systems, especially on a local level. in the Basque country we have a public nhS type of health care system. All health care professionals are salaried in both primary health care and hospital care. the important lesson of the past years is that despite this apparently tidy vertically integrated system in management terms, at the provider level this system has not achieved integrated clinical care and continuity of care. Management integration at all levels does not guarantee clinical integration where we need it at the provider level. it is therefore necessary to do something different. this Strategy provides the context to do something different.
  • 3. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrythe basic premise therefore is to avoid taking any policy decisions which might further fragmentcare and, rather, ensure we are developing local systems of care which offer continuity ofcare. consequently, the policy context in the Basque country will strive to build collaborationrather than competition and more concretely, what we propose is not a magic wand, but anorganized progression, activating many levers of change.investment is required in an information strategy and the technology to make it possible, it isnecessary to use new approaches to educate patients to manage their illness, to continue topromote evidenced-based medicine, and also to integrate primary care, hospital care andsocial care and to develop new professions which integrate care.iit is necessary to manage all these levers simultaneously. coordinated activation of all theselevers will provide the required set of tools with which to bring about the necessary change.they are presented here as strategic interventions which will enable us to meet the mostcomplex and important challenge of recent decades: that of organizing a health system worthyof the chronically ill, the most significant challenge of the 21st century.Although not in all cases, many of these new interventions will bring new efficiencies. theyshould all however and without exception provide better care and security for chronic patients.furthermore, many of our management and leadership concepts must change. none of thiswill be achieved with the kind of leadership we have known in the past. the complexity of thechange requires the development of a different leadership approach in the forthcoming decade.With the aim of reaching the necessary alignment between local and corporate level, we arecommitted to a better distribution of leadership, in which central management create theconditions to promote organization innovations which are inspired by local management andhealth professionals themselves. it is in this local arena in which the main innovations necessaryfor chronic patients will be found. rafael Bengoa Minister of Health and Consumer Affairs Basque Government 1
  • 4. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country2
  • 5. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryContentIntroduction 4The challenge and the opportunity presented by chronicity in the Basque Country 6 2.1 chronicity in the Basque country 7 2.2 the different needs of the chronically ill patient 13 2.3 reference and care intervention models for the chronically ill 14 2.4 What does the evidence say? 18The need for a system strategy 22The strategy for the Basque Country 26 4.1 Vision of the future 27 4.2 Policies 30 4.3 Strategic Projects 37Achieving change: Introduction strategy 60 Accepting complexity 61 top-Down and Bottom-up 62Index of tables and figures 66 tables 66 figures 67 Barring indications otherwise, this study is published under Creative Commons licence (BY) For further information and complete license: Photographs: ©M. Arrazola - EJ-GV (Unless otherwise indicated at the foot of the photo) Edited by Eusko Jaurlaritza – Basque Government – Department of Health and Consumer Affairs. Dep. Legal - BI-2345-2010 3
  • 6. Introduction
  • 7. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryWe often confuse interim short-term tactics with medium term strategies. the former canbe found in abundance, the latter are in short supply.this document provides a framework of action for the medium term transformation ofthe Basque health System. it is independent but complementary to the interim measuresand management policies that have been put in place due to the current economic crisis.While the interim measures attempt to reduce expenditure in the short term in order toensure sustainability, the final result of this Chronic Patients Strategy aims to outlinea new way of organizing care causing an impact on each and every aspect of the system(health results, satisfaction, patient and carer life quality, and sustainability). thus, thisstructural transformation goes beyond the current economic situation, requiring a longperiod (at least between 2 and 5 years) before achieving a substantial impact on expectancy for the Basque population has extended considerably in recent decadesand a significant parallel change has taken place in life styles. one consequence of thisis that the prevalence of people suffering from chronic illnesses is increasing to the extentthat the great majority of patients in our health system are suffering from one or morechronic illnesses.The response to the needs of people suffering from chronic illnesses has become theprincipal challenge faced by the Basque Health System (BHS). these pathologies havea multiple impact: they represent a considerable restraint on life-quality, productivity andthe functional state of people who suffer from them; they exert a strong influence onmorbidity and mortality rates; and they accelerate the increase in health and social costs,which compromises the medium term sustainability of the healthcare system.the path towards progress in this area requires a change in the existing conceptualframeworks, within which curing and caring, take place, and one which is clearly outlinedin the current health and social policies. The individuals and their environment, theirhealth and their needs have become the central focus of the System at the expenseof merely treating the illness.the existence of a higher number of chronic conditions in a person generally leads to agreater risk of incapacity and mortality, and within the chronic pathologies there are somewhich are notoriously disabling. this close relationship between chronic illnesses anddependence is the determining factor with regard to prioritizing and indentifying the mostsuitable health and social addition, chronicity implies a challenge to the quality of care provided, as the peoplewho suffer from chronic illnesses are more likely to receive less than optimum care andto suffer adverse pharmacological side-effects.furthermore, the challenge of chronicity requires proactive measures to combat the healthfactors which give rise to it in the first place. hence the importance of anticipation, settingup a framework of action which reduces its emergence and progression by means ofawareness and preventive summarize, chronicity is a in system terms global challenge and consequently requiresa systematic response. Beyond particular illnesses or specific groups of sufferers, it is achallenge which must take into account everything from the structural conditions andthe lifestyles which contribute to the increase of the pathologies in question to the socialand health requirements of the chronically ill patients and their carers: from the initialstages up until the care provided during the final phase of life, including all aspects ofcare, convalescence, and rehabilitation.This Strategy aims to improve the health and welfare of all people who are affectedby chronic illnesses, as well as to reduce both the level and the impact of chronicity. 5
  • 8. The challengeand theopportunitypresented byChronicity inthe BasqueCountry
  • 9. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country2 .1 T h e c h a l l e n g e a n d T h e o p p o r T u n i T y presenTed by chroniciT y in The basque counTrythe prevalence of chronic illnesses increases according to age groups in all cases, butconsiderably so for those aged over 65, diabetes and osteoarticular pathologies reflectingthe highest the majority of pathologies, an increase can also be observed in the prevalence amongthe over 85 age group, especially in the case of neurodegenerative dementias.comparing the most recent data (eScAV’07) with the prevalence data for chronic problemsincluded in the Basque country health Surveys from 1997 and 2002, it can be seenthat the percentage of chronic patients increases in the over 45 age group, which is ofparticular concern in the current context of population ageing, and, logically, an increasein the more advanced age groups is to be expected in the near future.According to the Basque health Survey carried out in 2007 (eScAV’07) 41.5% of men46.3% of women stated they were suffering from at least one chronic health problem.As can be seen in figure 1, the prevalence of chronic problems was higher in womenthan in men (with the exception of the under 17 age group) and this difference increasedwith age.Figure 1Prevalence of chronic problems according to age and sex 100 90 80 70 60% 50 40 30 20 Men 10 Women 0 <17 18-44 45-64 >65 Agefuente: elaboración a partir de eScAV 2007Similarly, among the elderly (over 65 years of age) it is not uncommon to find personswith multiple chronic pathologies. Patients with this profile run the risk of suffering somekind of disability or death. 7
  • 10. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Figure 2 Distribution of the population aged over 65 according to the number of chronic problems 8,6 % 23,4 % None One 28,9 % Two Three or more 39,1 % Source: Data from eScAV 2007 in fact, the clinical data provide a clear vision of the number of chronic conditions according to patient age, as can be seen in figure 3. Figure 3 Distribution of patients according to the number of chronic illness by age 80% 70% 60% 50% 6+ illnesses % 40% 5 illnesses 30% 4 illnesses 20% 3 illnesses 10% 2 illnesses 0% 1 illnesses 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95+ Age Source osabide 20078
  • 11. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrythis multimorbidity reflects conditions which are particularly representative, not leastwhen it constitutes a wide spectrum of chronic illnesses combined in different ways.Figure 4Main medical conditions appearing in patients with multimorbidity(3+ chronic illnesses) according to the primary care diagnosis70% 65%60%50% 39%40% 35%30% 23% 18%20% 13% 10% 9% 9%10% 5% 4% 0% n ia es s n ia C n a I re CC iti m sio i io O m em pa ilu t hr be h ss EP pe en st fa h al rt re ia isc A li t A ic ey ep er D er rv ac dn ypyp D Ce i H kiH rd Ca ic n ro ChSource osabide 2007from the comparison of the most recent data concerning the prevalence of chronicconditions (eScAV’07) with the data from the health Surveys in 1997 and 2002, it canbe observed that the percentage of chronic patients is increasing, above all in the moreadvanced age groups (figure 5). for example in the case of persons aged between 45and 64 in 2007, compared to the figure for 1997, there were almost 90,000 more peoplewho declared some kind of chronic ailment.Figure 5Change in the percentage of persons with chronic problems between 1997 and2007 according to their age 90 80 70 60 50% 40 1997 30 20 2000 10 2007 0 <17 18-44 45-64 >65 AgeSource: eScAV 9
  • 12. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country in fact, a retrospective analysis of certain illnesses reveals that their prevalence is increasing at a considerable pace. Figure 6: Change in the prevalence of diabetes and cardiovascular disease in the Basque Country In 15 years the prevalence of chronicity in the Basque Country has increased notably throughout the region Percentage 1992 1997 2002 2007 4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 9,1 - 10,5 10,6 - 12,0 Source: eScAV 1992, 1997, 2002, 2007 in order to provide a more detailed picture of chronicity in the Basque population a series of illnesses was selected according to the following criteria: • the principal diagnosed chronic illnesses (neoplasias were not included due to their special characteristics) • the main causes of mortality. the following figure outlines the number of chronic patients aged over 18 with each of these conditions, along with their prevalence according to the diagnoses in Primary care. it can be observed that the osteoarticular pathologies along with diabetes are the most common illnesses among the Basque population. Figure 7 Number (and prevalence) of chronic patients over the age of 18 suffering from the principal pathologies (according to diagnoses in Primary Care) Arterial Hypertension 172.820 (10,33%) Hypercholesterolemia 117.280 (7,01%) Osteoarticular Pathology 74.402 (4,45%) Diabetes 71.656 (4,28%) Asthma 34.154 (2,04%) Cardiovascular Diseases 33.246 (1,99%) Neurodegenerative Dementias 23.153 (1,38%) COPD 22.995 (1,37%) Obesity 18.469 (1,10%) Source: own data from osabide10
  • 13. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country A more detailed analysis on the age distribution of these chronic pathologies indicates that the degree of prevalence is increasing, in almost all cases, considerably so from the age of 65, with the increase being especially notable in the osteoarticular pathologies (>13%) and diabetes, which reaches a prevalence level of above 12%. neurodegenerative dementias become particularly apparent from the age of 85 onwards. Figure 8 Prevalence of the principal pathologies by age groups (according to diagnoses in Primary Care) 25,00 20,00Prevalence (%) 25,00 10,00 18 a 44 5,00 45 a 64 65 or above 0,00 C s a r s ar la tia te hm O ul cu be EP en tic st as ia em A ar ov D eo D i rd st Ca O Source: own data from osabide 11
  • 14. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country the study carried out by the Department of health in 2008 “the impact of different illnesses on the health of the Autonomous community of the Basque country” reveals that, among the selected illnesses, those with the greatest influence on mortality rates for men were the cardiovascular and ePoc diseases, which caused 16.4% and 6% respectively of all deaths. in the case of women, cardiovascular illnesses were also the major cause of deaths (17.3%), while diabetes was the second most dangerous (3%). on the other hand, in spite of not having such a high impact on mortality rates, osteoarticular pathologies are very relevant in as far as disability is concerned. the study estimated that out of all males suffering from a disability, 26.6% could be attributed to this kind of pathology. As for women, the influence of these illnesses on disabilities was even higher, with a prevalence of osteoarticular pathologies among disabled women of 45%. this situation of prevalence and increasing incidence of chronic pathologies is not a phenomena limited only to the Basque country, but one which is also taking place throughout Spain, with an expected annual increase, according to the prevalence data from the Patient Base of Decision resources, of approximately 1.2% in the number of type 2 diabetics among the Spanish population aged over 20, rising to affect some 7.7% of the population by the year 2016. this increase in prevalence also occurs, to a greater or lesser extent, in a great number of regions throughout the world, being, furthermore a tendency, which according to forecasts, will continue to increase, aggravating even further an epidemiological situation which is already very serious. Figure 9: Illustration of the forecast for chronic illnesses throughout the world – Example Diabetes A nivel mundial las enfermedades crónicas tienen las características de una pandemia en expansión. On a global level chronic illnesses bear the characteristics of a pandemic in expansion <4 4 to <8 8 to 14 >14 Forecast of the change in levels of diabetes on a global level(1) 2007 2025 Source International Diabetes Federation Source: international Diabetes federation: Diabetes Atlas12
  • 15. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 2 . 2 d i F F e r e n T i a l n e e d s o F T h e c h r o n i c a l ly i l l paT i e n T Although chronic illness is defined by a standard list of defined pathologies, it does present a series of differential factors: long duration, slow and continuous progression, it decreases the quality of life of those affected, and frequently reflects a significant level of comorbidity. furthermore, it is a cause of premature death and has significant economic repercussions for families and society in general. for the purposes of analysis and the approach followed in this document the following list and characteristics have been used. Table 1: list (not exhaustive) of chronic illnesses and their characteristics Chronic illnesses are very widespread and have certain characteristics in commonPossible illnesses consideredchronic Common characteristics 1 They have multiple causes and complications Diabetes mellitus 2 They normally appear gradually, although they can appear Cardiovascular diseases suddenly and present acute states (Ischemic cardiomyopathy, cardiac insufficiency, cerebral 3 They emerge throughout the life cycle though they are more vascular illness) prevalent in the elderly Chronic respiratory diseases 4 They compromise the quality of life causing functional limitations (EPOC, asthma) and disability Osteoarticular diseases 5 They are long lasting and persistent and result in a gradual (rheumatoid arthritis and severe deterioration in health arthrosis) 6 They require long term medical care and attention Neurological diseases (epilepsy, 7 In spite of not being immediately life threatening they are the Parkinson’s disease, multiple most common cause of premature death sclerosis) 8 In some cases they are limited to non-contagious diseases, Mental illnesses (dementia, although more recently they have been included illnesses such as psychosis, depression)) AIDS or tuberculosis HIV/AIDS 9 Fortunately, a significant number of them can be prevented or Digestive diseases (chronic their appearance can be delayed, while in others, given the level cirrhosis and hepatopathy, of current communication, their progress can be slowed down ulcerative colitis, Crohn’s and their associated complications reduced disease) 10 The distribution of the conditions and causes that favour the Chronic renal diseases … development of these illnesses in a population is not uniform, being the less well-off sectors which present greater frequency. The growing accumulation of risk factors in these less well-off groups will continue to increase the gap in health results Source: health Study and research Services of the Department of health and consumer Affairs of the Basque government Beyond the specific chronic illness or combination of illnesses, the focus of these differences is the phenomena of chronicity and the factors involved since its outset, the treatment, be it preventive, curative, palliative, or rehabilitation, up until the final stages, with the chronic patient in the centre of the care pathway. this evolving social construct which we call chronicity encompasses patients with different diseases and at different levels of seriousness. With this in mind, the focus of this document is global and is not devoted solely to specific diseases. 13
  • 16. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Whatever the particular illness, the most important factors in the interventions in chronic procedures are different to those for acute illnesses. 1. they require a complete diagnosis of the patient including their social situation and their role as opposed to a traditional diagnosis focussed on the illness and the acute symptoms. 2. Proactive, preventive (primary and secondary) and rehabilitation interventions are more important than a typically curative focus on the acute illness. 3. the patient and the carer play a much more important role in the successful outcome of the intervention with the need to change life styles and adhere to these over long periods in contrast to the traditionally passive role of the care receiver. 4. they require a coordinated approach to care with an “individual vision” at all levels of care (primary, specialized, medium stay, mental health, emergencies, social services, health at work, etc.) throughout the duration of the illness as opposed to a rapid and specialized action on the part of a limited number of specific departments. 5. the needs and priorities (medical but also emotional, social, material and even spiritual) of each patient are given more importance considering that we are often dealing with continual interventions over the remaining lifetime of an individual compared to a specific intervention which has a limited impact on a person’s quality of life in the mid-term. these differences in the focus of the interventions are such that the phenomena of chronicity requires a model of care different to that typically used for acute illnesses. 2.3 Fr aMeWorKs and care inTerVenTion M o d e l s F o r T h e c h r o n i c a l ly i l l currently there exists, at a global level, a broad base of highly developed theoretical models. in addition, in recent years, specific interventions have been outlined, the efficacy of which can be tested as they have been carried out in various health systems in different parts of the world. Specifically, in this section the main reference models have been included (ccM, iccc, kaiser Pyramid of care, the king’s fund Pyramid) along with some examples of interventions with scientific evidence. Probably, the outstanding international reference model for chronic patient care is the Chronic Care Model CCM developed by ed Wagner and by collaborators from the Maccoll institute for healthcare innovation in Seattle, in the uSA. in this model, care for chronic patients takes place on three overlapping levels: 1) the community with its policies and multiple public and privates resources; 2) the health system with its supplier organizations and insurance schemes; and 3) the interaction with the patient in the clinical practice.14
  • 17. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryTable 2Adaptation of the care model for Chronic Patients in the Basque Country Health system Organization of health system Self- Design of Medical Decision Community, management provision information support Resources and system systems Policies Activated Proactive Informed Productive Health Patient Interactions Team Medical and functional resultsSource- Developed by ed Wagner and collaborators from the Maccoll institute for healthcare innovation. Adapted by o+berriBasque institute of health innovationthis framework identifies six essential elements which interact among themselves andwhich are key to achieving optimum care for chronic patients. these are:• organization of the healthcare system.• Strengthening of links with the community.• fostering and support for self-care.• Design of the care system.• Decision making support.• Developing clinical information systems.the final objective of the model is that active informed patients become the protagonistsof the medical encounter along with a team of proactive professionals with the requisitecapabilities and skills, all in pursuit of a high quality level of care, increased satisfactionand improved results.Standing out among the adaptations of the ccM is the model proposed by the Worldhealth organisation, known as “The Innovative Care for Chronic Conditions Framework(ICCC)”. 15
  • 18. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Table 3 The Model of Innovative Care and Chronic Conditions (ICCC) Framework of Positive Policies Strengthening of alliances • Development and assignation of human resources • Policy integration • Support from the legislative framework • Guarantee of suitable financing • Leadership and support Health Organization Community Fostering continuity and coordination. Awareness and taking Prepared away stigma. Promoting quality through leadership and Promoting better results incentives. through leadership and en ity He team support. Organization and Ag mun alt s ts funding of the health hC Mobilization and coordi- care teams. m nation of resources. are Co Use of information Provision of complemen- d Mo systems. me tiv tary services. o Patient and ated r Support for self-care and Inf prevention. family Better results for chronic conditions Source: Who this model adds to the ccM a model health policy perspective of which the main ideas are the following: • Decision-taking based on evidence • focus on the health of the population • focus on prevention • emphasis on the quality of care and on system quality • flexibility/adaptability • integration, as the hard fractal core of the model Apart from the system models such as ccM and the iccc, the other type most frequently used is that which refers to population models, the focus of which is the population as a whole and its needs instead of those of the health care system. Standing out among these is the “Kaiser Pyramid” which identifies three levels of intervention depending on the level of complexity of the chronic patient. in posterior interpretations to the kaiser model the population aspect of promotion and prevention has been included. the main idea set out by the kaiser Pyramid is one of segmentation or stratification of the population according to its needs: in the patients with more complicated cases with frequent comorbidity an integral management of the case is required with the provision of fundamentally professional care. • high risk patients but whose cases are less complex as far as comorbidity is concerned receive a disease management approach which combines self-management and professional care. • the majority of chronic patients with conditions which are still incipient receive support for the self-management of their illness. • finally, the general population is the focus of promotion and prevention actions which aim to control the risk factors which might contribute to the development of chronic illnesses in individuals.16
  • 19. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryTable 4Extended Kaiser Pyramid Professional care Patients with severe complications (5%) Case Self-care Management Illness High risk patients (15%) Management Chronic Self-management support patients (70-80%) Promotion and Prevention General PopulationSource: kaiser Permanent. Adaptedone of the most interesting adaptations of the kaiser Pyramid which has been put intopractice is the pyramid defined by the king’s fund in the united kingdom. in this adaptationwhat stands out is the combination of the health and the social vision as two integralparts of the care requires by a person. 17
  • 20. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Table 5 Pyramid defined by King’s Fund in the United Kingdom Pyramid de ned by King’s Fund in the United Kingdom Adapt the service to the individual Social vision Health vision Support people Individuals with highly who have more needs at home; complex needs/morbidity; take them away from permanent residences Level 3 improve the care for chronic patients; Case separate them from acute care Management High quality support Higher risk patients; to carers at home Level 2 specific interventions Managing to combat the illness; early diagnosis the illness Appreciate people’s value; 70%-80% of individuals; investment in voluntary Level 1 health promotion; prevention services nutrition; exercise Self- Management Source: king’s fund (c.ham) 2 . 4 W h aT d o e s T h e e V i d e n c e s ay ? As well as conceptual frameworks of action, there have also been interventions in recent years which have offered scientific evidence of their effectiveness, revealing the possibility of improving results at different levels (health results, patient and carer satisfaction and quality of life, sustainability) by changing the way of managing chronic illnesses. nevertheless, the majority of these interventions have been carried out in particular health systems and their extension and adoption by other systems has been limited and difficult. this only underlines the complexity associated with the implementation of these interventions and the change in systems to the level required by the model. Among these interventions a significant number have shown improvements in patient and carer satisfaction levels (e.g. care coordination, case management, telemedicine). in relation to the results corresponding to health outcomes and efficiency improvements there are fewer specific examples with clear evidence (e.g. case management by nursing – Boyd/Boult). however, the systems which have given clear backing to these kinds of models (e.g. kaiser Permanente in the uSA, Jonkopping, in Sweden, various area health authorities in england, canada, new Zealand and Scotland) in general demonstrate better health outcome results than comparable institutions with a high level of efficiency. for the design of this Strategy for tackling the challenge of chronicity in the Basque country we have taken into consideration: • the reference of the models outlined above, as well as the interventions which have proven to be effective. • the collaboration of the international centres of excellence mentioned above, many of which were represented at the international congress organized in Bilbao (2nd-3rd June 2010) with the objective of contrasting and comparing their experiences with the strategic proposal designed for our situation.18
  • 21. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country• the thorough national and international analyses of all the evidence relating to the management of chronic illnesses.We include below in the section “ the relationship with health Systems Sustainibility “ asummary of the most significant conclusions of these is important to highlight that the evidence in favour of the interventions indicated in thisStrategy is growing, indicating that there are numerous opportunities for the Basque healthSystem.indications are that investments in this line of action in general will be beneficial for patients,will be cost-effective, will reduce the number of hospital admissions, that they will improveefficiency and will reduce the mortality rate.The relationship with Health System sustainabilitythe basic notion resulting from these studies with regard to efficiency can be resumed asfollows:• it is necessary to organize a system which is able to deal with comorbidity and not merely to deal with one illness at a time, (35% of people aged over 80 suffer from two or more chronic illnesses).• the most significant potential benefits arise from the prevention of the unnecessary admission of complex patients into the hospital system.• the cases which activate a sole intervention (e.g. remote medical monitoring from home, or training patients for self-management) may not achieve the desired efficiency impact. to obtain efficiency improvements, it is necessary to systematically intervene, working several levers of change, using the models outlined above in an integrated and coordinated fashion.• economic results will appear in the mid term.• it is worth “noting down” the management interventions of chronic patients according to the predictions of high use (e.g. recent hospitalization, frequent use of emergency wards, certain medical indicators). By acting in this way, saving opportunities will be substantially enhanced.• individualized planning previous to admission and advice from multi-disciplinary teams guarantees substantial reductions in avoidable re-admissions, even in the absence of other interventions.• When patient groups are easily identifiable and classifiable, face-to-face interventions which combine education with clinical care including contact with primary care or hospital specialists, as well as remote electronic monitoring are considered worthwhile in efficiency terms. consequent reduction in use and expenditure tends to be positive.• intensive and individualized education combined with treatment is more effective with diabetic patients (with the exception of the elderly) and with asthmatic patients.• interventions based on opportunistic education during the patient-doctor interaction tends to be less effective compared to highly intensive educational interventions focussed on patient self-management.• interventions for the management of congestive cardiac failure and for the elderly with multiple conditions have proved to be the most fertile area for achieving health improvements and relevant economic savings.• Studies confirm an positive return on investment in congestive cardiac diseases, asthma, and with patients with multi-pathologies. the main saving would be in the fall in admissions and readmissions as well as in daily costs.1 Chronic Disease Management: Evidence of Predictable Savings; J. Meyer and B. Markham. 2008 19
  • 22. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country • in asthmatic patients the saving is substantial due to the reduced use of the emergency services. • in chronically ill patients who were treated more intensively and individually, the fall in hospital admissions was from 21% to as high as 48%; with asthma patients in particular, the fall in admissions ranged between 11% and 60%. in diabetics hbA1c values dropped by 1% and hospital admissions fell from between 9% and 43%. Among elderly patients with multiple pathologies the fall in hospital admissions was from between 9% and 44 %. Although the evidence on the impact of the management of chronic care is heterogeneous and generalizations should be carefully evaluated, the overall analysis indicates that significant and foreseeable savings could be achieved. this data confirms the growing interest in this line of work to ensure the SuStAinABility of the Basque health System. therefore the new Strategy for the Basque health Service has been designed along these notions.20
  • 23. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 21
  • 24. The needfor aSystemStrategy
  • 25. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country As has been discussed in the previous section, in the Basque country, chronic illnesses represent the dominant epidemiological situation of the country. it is estimated that they currently represent 80% of the interactions with the Basque health System and account for more than 77% of health expenditure. however, the basic characteristic of the current care model is reactive, in which the patients have an episodic relationship with the health system and this logic is not what chronic patients need. in fact the current System is designed and structured to comply with an epidemiological model focussed mainly on acute interventions which do not correspond to today’s needs. furthermore, there is a lack of integration between the health system and the other social resources associated with health, which, as has been seen, is of substantial importance for chronically ill patients. Table 6: The reactive nature of the current system The health system is still mainly reactive Population has not We do not have We do not have been stratified... case nurses... routine medical reminders... Care is fragmented... Patients are The patients who could not activated... be are not telemonitored Source: own elaboration the structural tendency towards the increasing relevance of chronic patients means that it is absolutely necessary to respond to their needs, both from the point of view of health results and in order to guarantee the sustainability of the system in a situation in which there is increasing pressure on expenditure. Based on the above (epidemiological challenge, chronic patient needs, international evidence….), this Strategy has been drawn up in order to adapt the Basque health System to the current demands and those of the future in areas of prevention and care for chronic illnesses. it is important to point out that this strategy is not a repudiation of the excellent management of acute illnesses, but one which complements the current acute organisation with the capacity to also respond adequately to the needs of chronic patients: 1. the challenge of chronicity goes beyond the illness and the symptoms, so the Strategy needs to broaden its vision of the individual: not only their biomedical situation but also their social and functional situation. 2. tackling chronicity also requires overcoming the conventional programmes of episodic treatmen. it is necessary to try and reduce the appearance and the adverse effects of chronic illness by means of a population approach in which prevention and health promotion are key elements.istockphoto - getty images 23
  • 26. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 3. the patient and their carer cannot be passive elements in this strategy. they have a central role which requires training and an increased awareness beyond that of their traditionally passive role. 4. chronicity requires a holistic vision of the patient and an all-embracing and coordinated focus both from within the health system (primary, specialized, medium-stay, mental health, emergencies) and from beyond, embracing the institutions, Departments, Programmes and available technologies and infrastructures directly related to chronicity (social assistance, sport, health at work). 5. finally, chronicity requires that the range of available interventions is widened and adjusted to the needs and priorities of the patients in each of the phases of their illness (from the outset to the end of their lives, embracing convalescence and rehabilitation). this new strategic approach is supported by international trends and by the increasing evidence of the effectiveness of the interventions and models mentioned in the previous section, more in tune with the needs of chronic patients. All in all, the Strategy is presented as an opportunity for change in the model to one in which the agents involved participate in the establishment of a framework of action for an integral management of chronicity from the population perspective, building upon the existing capabilities of the system. the following table shows a series of emerging elements which complement the existing model in the interests of achieving the aforementioned change. Table 7 Towards a new model for the Basque Health System Current Elements Emerging Elements Accessibility face–to-face remote Product health services health value Architecture Supplier focussed citizen focussed of Service and of Quality of the System Management • continuous and • episodic coordinated Care Model • reactive • Proactive • hospital focussed • integrated • health • Accessibility Value Proposal • Prevention, cure, care • focussed on care and rehabilitation Source: osaberri24
  • 27. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 25
  • 28. The strategyfor theBasqueCountry
  • 29. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country the strategy designed for the transformation of the Basque health System along the lines mentioned above is structured in the following way: • it is based on a medium term Vision, which defines and describes the desired future situation. • it describes the health care Policies for chronic patients as guidelines for the successful fulfilment of this vision. • finally, there is a series of Strategic Projects which contribute towards generating and implementing the change to make the policies and the vision a reality in each one of its dimensions. Table 8 Strategic Diagram 1 - Vision 2 - Policies 3 - Strategic projects 4 .1 V i s i o n o F T h e F u T u r e the Basque chronic Patients Strategy aims to respond to the needs generated by the phenomena of chronicity in all the affected groups: chronic patients and their carers, health workers, and citizens in general. • for the chronic patients and their carers it will mean changing from a reactive system to a proactive system which will offer them a more integrated level of care (coordination between health levels and alignment with the social and employment agendas), more continuity during the development of the illness (from prevention to the end of life, including rehabilitation) and be more adapted to their needs. furthermore, they will be given a role to fulfil and greater responsibility in the management of their own health. All with the final objective of being able to offer patients better health results, with greater levels of satisfaction as far as care and quality of life are concerned.istockphoto - getty images 27
  • 30. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country • for medical professionals it will represent the possibility of devoting more time to work on issues of higher added value and having access to the necessary tools (e.g. more complex diagnostics in primary care, tools to support changing patients behaviour). furthermore the idea is to that the time invested in routine work will be automated (e.g. prescriptions for long term treatment, coordination of the clinical history between levels of care, basic health advice by telephone, case management by nursing) and the tools will be given to the patients themselves or the carer. • for citizens there will be a double benefit. As tax payers they will benefit from a more efficient use of the systems resources, with the type and cost of each intervention being adjusted to meet the attention and care needs of each case, thereby contributing to the sustainability of the system. As potential chronic patients, they will participate in the prevention of chronicity and the promotion of their own health, avoiding the development of chronic conditions or at least reducing their impact on their health and quality of life. • for non-medical professionals and health service managers it will mean that their role will be given more recognition, they will have confirmation of their impact on health results and not only on the efficiency of the system, their co-leadership will be broadened, they will witness the breaking of barriers which limited their area of action and responsibility, as well enjoying the opportunity to share with other professionals new areas of influence and collaboration. Table 9: Vision of Strategy for Chronic Illnesses The Strategy for Chronic Illnesses aspires to substantially improve the lives of patients and carers, health professionals and citizens Vision Better health results Greater life satisfaction and Chronic Patients and quality their Carers Basque Health More time for work system adapted to E cient use of which has greater resources added value deal with Chronicity Prevention of Fewer routine chronicity and its Health jobs Citizens development Professionals28
  • 31. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrythis change will have an impact both on Primary care and on hospital care. it is not aquestion of deciding where care should be provided, but accepting that care for chronicpatients nowadays is suboptimal mainly due to the lack of care continuity between ourlevels of care. thus the logic of this Strategy is based on the premise that we are facedwith a problem of organization of clinical and preventive practices, both with regard toprimary care and hospital provided is still basically reactive to acute illnesses and episodes; that is, in a modelof acute illnesses the premise is to define the problem which is the subject of the clinicalconsultation, to diagnose it and to initiate a treatment, usually pharmacological. theconsequence of this model of organization is that, when it is applied to a chronic patient,that patient receives care which is more episodic than continuous, as this is how the systemhas been conceived. Moreover, the consultation is normally determined by the acuteproblems from which the patient is suffering. All this leads to a reactive model.By contrast, we propose moving to a model of organization which is more proactive in orderto ensure:• that patients have the confidence and the skills to manage their illness.• that patients receive care that provides optimum monitoring of their illness and prevents complications.• that there is a continuous monitoring system both remote and face-to-face.• that the patients have a self management plan, which has been mutually agreed with health professionals, with which to control their illness.• that we develop an organization with a preventive and continuous care logic, which is designed between the patient and the clinical team.experts agree that it is preferable to manage chronic illnesses in primary care, and themodels outlined in Section 2.3 of this document are based upon this logic. this strategycontinues this line of work, but it indicates that hospitals should also be innovative in theirmanagement of chronic patients, as in many cases they have to be admitted to hospital.thus hospitals play a fundamental role, as treating chronic patients during their acuteepisodes is part of the integral management of those patients.finally, what we are dealing with is a process of change which combines uniform elementsfor all patients and agents of the system – an essential ingredient to guarantee the necessarylevel of standardization in an ambitious strategic change – with the necessary adaptationof various local situations arising from users and service organizations. for this reason, wedefend the need to better balance the dichotomy between the corporative and the localperspective. that balance is achieved with certain global strategic frameworks, whichemanate from the centre and extend uniformly throughout the system and with the necessarylocal freedom required for local application. this balance is further explained in the lastchapter of this realize this vision, it is necessary, not only to provide the system with the necessarytools, but also to change substantially the “way of doing things”, with respect to theorganization of care; a change to be made both by the patients themselves and by thesocial and health care professionals and managers. these changes are defined in the fivePolicies of care for chronic patients explained in the following chapter. 29
  • 32. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 4.2 policies the policies described below correspond to the principal areas requiring change in order to be able to suitably address prevention, care, rehabilitation and health care for chronic patients. As has been previously mentioned, these polices do not aim to replace the current system of handling of acute illnesses, but in fact to complement it in order to be able to offer excellent and efficient care to chronic patients. to put each one of these policies into action, it will be necessary to strengthen the system in various areas, in order to prepare a more adapted model geared to managing the phenomena of chronicity. this section will focus on describing the aim and expected results of the policies, while details of the concrete strategic projects can be found in the following section. POLICY I. Adoption of a population health outlook, stratified and proactive population Table 10: Policies Health care for chronic patients will change with the introduction of five strategic policies I Focus on strati ed population health Policies II Promotion and Prevention of chronic illnesses III Responsibility and autonomy for patients IV Continuous care for the chronic patient V E cient interventions adapted to the patient’s needs Source: own elaboration health management and reduction of inequalities in health matters. Objective the objective of the focus of population health is to improve the health of the entire population and reduce the potential level of health inequality. this focus will also enable the analysis of the complexity and comorbidity levels of the population, and its segmentation with the aim of targetting resources to cover the different needs in a tailored and proactive way. Context and Focus this policy recognises both the diversity of the social, economic and environmental factors which influence the development and evolution of chronic illnesses, and the behavioural factors which affect health. it also helps identify how these causes determine the inequalities. in this way the specific needs of the different levels of the patients in question are responded to: from those who are in the final phase of their lives (receiving palliative care) to those who, although not yet chronically ill, present a series of risk factors which identifies them as potential chronic patients in the future; as well as recognising and facing up to the specific requirements of population groups such as the elderly and those who find themselves in a precarious social30
  • 33. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryor economic situation (the groups most affected by chronic illnesses and in need of specificsocial interventions).focussing the policy in this way, the prevention and care for chronic illnesses must respondto the needs of the people from all backgrounds, both cultural and linguistic; of every age,from children to the elderly; from all socio-economic classes; from all areas, both rural andurban, and with no disparity between men and women.Specific Resultsthe result of this policy will be to identify the “target” groups of patients for certaininterventions. this requires both a stratification of the population according to their clinicalrisk and their health and socio-health needs, and also the association of each level ofstratification and patient typologies with the kind of interventions that evidence has provento be effective for chronically ill patients in the Basque country. eventually, this will allbe integrated in information systems and in the daily clinical duties of the medicalprofessionals, thereby personalising the treatment received by each patient.this integration is fundamental, as the stratification of the population and the populationfocus which it enables is a first essential step towards setting in motion the rest of thechronic illness management policies.furthermore, stratification will help bring about the change in mentality from a “patient”focus to a “population” focus which considers the individual beyond the acute episodesand also embraces prevention, rehabilitation, and medium-term care.Table 11Diagram of a possible pyramid of population stratification Patients with severe complexity Requires urgent health care coordination Level 4 ies vit Patients with medium level complexity cti Level 3 Suffer from complications and need na a certain level of management tio en Patients with reduced complexity ev Level 2 Well managed Pr Recently diagnosed Patients with no chronic illnesses Level 1 Healthy populationSource: Adaptation of the kaiser Permanente risk stratification 31
  • 34. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country POLICY II. Prioritisation of health promotion and the prevention of illness. Objective A considerable number of chronic illnesses and their risk factors can be prevented and, consequently avoided. once they are present, their early diagnosis and detection often enables their progression and their negative and disabling effects to be limited. the objective of this policy is to create a framework of action, including proactive prevention measures and health promotion actions with regard to chronic illnesses, aimed at the different levels of the population pyramid: both for the healthy and for those persons with risk factors, as well as those who are already suffering from one or more chronic illnesses, but always emphasising an integral population approach. Context and focus Specifically, some risk factors such as the consumption of tobacco, alcohol, or other drugs, lack of physical activity, a badly balanced diet or unhealthy working conditions can be controlled, thereby avoiding the appearance and progression of a high proportion of many chronic illnesses. the aim, therefore, is to put tried and tested measures and interventions into action with the aim of preventing chronic illnesses. interventions will be combined both at an individual level and at the level of patient groups and risk groups. the proposal of specific interventions for health promotion and prevention of chronic illnesses must, necessarily, take into account the available scientific evidence. thus, the use of information systems and risk stratification of the attended population may be of great benefit when it comes to carrying out interventions at a more efficient level. health promotion actions must be aimed at raising awareness and informing the citizens about their health, at improving their lifestyle habits, at raising their awareness with regard to certain risk factors. As far as prevention actions are concerned, these must be introduced both at primary and secondary level care, stressing the usefulness of early detection in primary care and the capacity for contention of progression of the illness in secondary care. Specific results resulting from the policy will be an integrated set of prevention and health promotion actions of proven effectiveness in the Basque country, both at primary and secondary level, aimed at target groups of patients according to the results of the stratification. these actions should significantly reduce the prevalence of chronic illnesses and the deterioration in health of those patients who suffer from them. POLICY III. Promoting the active role of the citizens, encouraging their responsibility in the management of their disease and in patient autonomy Objective Promoting the increasing role of the citizen in dealing with chronicity. on the one hand, with self-care on the part of the chronic patients and their carers, as an essential lever to reach personalised based care with the necessary support of the healht care system at all levels. Self-care requires the active participation of the patients and their carers in administering healthcare and in the process of making informed decisions which are agreed on with the doctor, the patient and the carer. on the other hand, it requires their active participation in their own health promotion and the prevention of the appearance and development of chronic illnesses.32
  • 35. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryContext and focuscare which is focussed on the individuals places them at the centre of their own healthcare, converting them into active patients and administrators of their own state of health.however, the traditional role of the patient and the carer in the health system is passivewith all the responsibility and knowledge centred on the doctor. this traditional role is upto a point coherent from the point of view of acute illnesses in which immediate anddecisive action is required in the case of a complex episode in which the patient onlyoccasionally participates. A chronic procedure, however, has long reaching effects andrequires intervention over a long period of time. Moreover, the patient or carer hasconsiderable influence over the effectiveness of the treatment and the progression of theillness depending on the rigour with which the treatment is adhered to and the lifestyleof the patient (e.g. tobacco, exercise, obesity).therefore, it is crucial to change the conventional role of the passive patient, receivingcare from the system, to that of an active patient/citizen, accountable for their own careand illness prevention.of course, the degree of participation and accountability of patients and carers is different,depending on the type and complexity of the process, the level of independence, andthe social-health situation of the patient. in any case, all patients and carers have theopportunity to participate in their care to an extent, as patients can be supported in thedevelopment of specific skills and resources in order to maximize their capability for self-care.Specific resultsthe specific result of this policy will be an array of interventions and tools which will enableself-management and promote the accountability of patients with regard to their owncondition. these interventions and tools will be incorporated into the daily clinical routineof the health professional –and in that of the social workers when relevant- and will be easilyaccessible and extensively used by the patients and their carers, with the support of patientsassociations. the eventual consequence will be a stricter level of adherence to the treatmentand lifestyles necessary to control and prevent the illness, and a more efficient use of theresources of the health and social systems.POLICY IV. To guarantee continuous care through the promotion of a multi-disciplinarycare programme, co-ordinated and integrated between the different services, carelevels and sectors.Objectivecare for citizens suffering from chronic pathologies involves numerous health care providersin different scenarios, such as Primary, Secondary and tertiary care, medium and longstay rehabilitation centres with a focus on acute and sub-acute cases, mental healthcentres, the social-health sector, health at work, community organizations and ngos,etc.integration and continuity in the provision of care are essential elements with which toguarantee that the necessary services are received at the right time and in the right way,optimizing health results and improving the experience of “the journey through the system”,in a process which begins with initial prevention and goes beyond the worsening of achronic illness until the point at which rehabilitation permits the citizen to resume a normallife. from the professional point of view, the target is to promote coordination to avoidduplication and to reach optimum management with regard to transitions between carelevels. 33
  • 36. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Context and focus this requires a flexible system, capable of coordinating services, suppliers, locations and sectors over time. this, in turn, requires a commitment from all actors and the capacity to work in a team in order to achieve common objectives. the provision of services must be programmed and coordinated in order to attend to the needs of patients and carers, in accordance with quality standards and clearly defined care procedures (e.g. promoting the application of medical guidelines). the existence of multidisciplinary teams, shared care tasks, skill training for professionals, and the taking on of new roles are fundamental to ensure the effectiveness and the continuity of patient care. in short, the key for a system organized to improve planning, integration and continuity of chronic patient care should revolve around: • the coordination-integration of care measures. • the promotion of multidisciplinary teams. • the development of a model of subacute hospitals. • Strengthening the role of Primary care. • care planning. • the design and effective introduction of new professional roles and profiles. • Strengthening rehabilitation as a key pillar in the system. Specific results the specific result of this policy would become evident in all those mechanisms, roles, social - health care agreements, clinical procedures/protocols/paths and tools which are necessary to guarantee continuity of care for the chronic patient between the different people and organizations involved, both health and social, and in particular during the transitions between different levels of service. in a practical way, virtual multidisciplinary teams would be set up which would share information and diagnoses in a transparent fashion. the eventual consequence for the citizen would be care which was better adapted to their needs and their situation within the cycle of the illness (from prevention to rehabilitation), a product of the integrated vision of the information and the reduction of the number of unnecessary interactions, caused by the lack of coordination between care levels, while the health professionals and social workers take on new roles which will enable them to focus on improving the health and the situation of the patients, and to avoid repetitive work and carrying out tasks of minor added value. POLICY V. To adapt the health interventions to the needs and priorities of the patient and the efficiency of the system. Objective to develop a patient centred system which chooses the optimum health intervention from a wide range and adapts it for the chronic patient in each situation, taking into account: • in first place, the needs and priorities of the person, bearing in mind that behind each medical record there is an individual with a series of personal, emotional, social and psychological needs, seeking the most humane care and that which is less aggressive, disruptive and intrusive for the life of the patient (e.g. a ten minute visit may require up to four hours of disruption in the patient’s life) with special emphasis in the case of those patients in palliative situations. • in second place, the needs and priorities of the patient, their carers and their environment, with an integrated vision of their pathologies, progress and previous34
  • 37. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country interactions with the health care system, searching for the intervention which would achieve the best health results.• in third place, the needs of the health care System itself, ensuring an efficient and responsible use of resources at all times, guiding the patient towards the least intensive level in technology and care, compatible with their medical situation and also seeking alternatives to reduce the burden on activity and economic resources.Context and focusthere is growing evidence which indicates that the best results of a system require takingsteps beyond mere medical considerations of the situation of the patient; that is, thetaking into account of their priorities, involving them in the decisions and choice oftreatment. We must move towards a healthcare model which reduces the level of intrusionof healthcare action in the daily life of patients.furthermore, technological and management advances have enabled the extension ofthe range of health interventions available beyond the traditional doctor’s appointment.telecare, telephone consulting, internet consulting, electronic prescription… are just afew of the examples of current alternatives available for a health service, which arepromoting the home as the main location for the provision of health and social care forchronic patients, with the increase in programmes such as home based hospitalizationand other forms of home care.Moreover, the growing and unstoppable pressure on the system, both in terms of healthservice activity and in terms of the limitation of available economic resources, calls forthe need to search for more efficient interventions which do not diminish the level of care,patient satisfaction or the clinical results.All this is particularly important for the chronically ill who have a continuous interactionwith the system throughout a period which could last several decades. these patientsneed particularly humane and less intrusive treatment, as their relationship with theSystem will not be a one-off or occasional episode but an integral part of their lives. Andit is these patients which the system needs to treat in the most efficient way possible, asthey make up a disproportionate part of its activity, and they have some needs which aredifferent to those of acute patients, with less need for curative intervention and moreneed for monitoring and rehabilitating interventions.for this reason, the aim is to introduce new kinds of interventions, to reinvent and adaptthe current ones and readdress the balance of the different available services. the aimis also to take advantage of the understanding of the stratified needs of the patient andthe unique social and health vision of each person and their interaction with the system,aspiring to a situation in which each patient receives at all times the intervention whichbest fits their needs and priorities as a person, as a patient and from the point of view ofthe efficiency of the health system.Some specific examples are: the introduction of the possibility of interacting virtually withthe system in order to obtain a more practical and quicker response: an increase inemphasis on rehabilitation actions with innovative rehabilitation programmes (e.g.collaboration with sports centres), electronic prescription which avoids the need to maketrips to health centres to pick up long-term treatment prescriptions, home basedhospitalization or in sub-acute hospitals for all patients whenever it is medically compatible,lessening the impact of care on a person’s life as well as reducing the cost for the System(e.g. a bed in a hospital for acute treatment can cost twice as much as one in a sub-acutehospital, without providing the chronic patient with a lower level of care due to thediagnosis). 35
  • 38. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Specific Results the specific result of this policy will be a systematic adaptation of the different interventions to personal needs and priorities, both those related to health and to the system, in such a way that interventions will neither be more intrusive nor more costly than strictly necessary, and furthermore, the decision regarding intervention will be increasingly shared between the professional and the patient. in practical terms, it includes the substitution of face-to-face interventions for remote or automatic interventions whenever possible, adapting the level of care (e.g. beds for acute patients, beds for long stay, home hospitalization), promoting rehabilitation and preventive interventions and reducing unnecessary visits. the eventual impact will be greater satisfaction levels both for patients and for professionals, greater quality of life, better health results and comparatively lower costs. Table 12: Interventions adapted to the patient’s needs It is crucial to adjust the type of intervention to the needs of the patient so as to ensure an efficient use of resources Self Telephone Appointment Doctor’s Appointment Case Home Mid-term Chronic care consultation with nurse PC appointment with specialist management hospitalization hospitalization hospitalization with doctor PC 700-900€ Cost per 400-500€ action / stay €/day 50-200€ ~50€ 100-150€ 0€ <10€ 25€ 35€ Level of Care for basic simple needs Medical Complex Specialized Interaction of Basic medical Intermediate Advanced analysis and diagnoses PC complex care and monitoring medical medical attention intermediate diagnoses integral monitoring monitoring care management Level of Minimum Limited 1-3 hours to including travel 2-5 hours Periodic Changes at High level of Very high level disruption for and appointment including travel contact home and disruption of disruption the patient and frequent appointment visits/contacts Source: estimates made by osakidetza, data from osabide and international examples, own elaboration36
  • 39. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 4 . 3 s T r aT e g i c p r o J e c T s A series of Strategic Projects is currently being launched to an advance towards the policies outlined in the previous section, building progressively a new model for chronic illness for patients, professionals and citizens in general. Table 13: Strategic Projects within the Chronic Illness Strategy Policies are introduced by way of 14 strategic projects Vision Strategic Projects Population Prevention and Patient Continuity Adapted Focus Promotion autonomy of care interventions1 Stratification and 2 Interventions aimed at 3 Self care and patient 5 Unified Medical record 11 OSAREAN: targeting of the the principal risk factors education: Active Multi-channel Centre population (e.g. giving up tobacco, Patient – Paziente Bizia 6 Integrated medical care prescribing a healthy 12 e-prescription life, care for the elderly) 4 Setting up a network of 7 Development of activated patients, sub-acute hospitals 13 Chronic illness research connected through the centre adoption of new Web 8 Advanced nursing 2.0 technologies by the responsibilities Chronic Patients Associations 9 Socio-health collaboration 10 Financing and contracting 14 Innovation on the part of the medical professionals Source: estimates made by osakidetza, data from osabide and international examples, own elaboration 37
  • 40. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 1. Stratification of the population the proposal of this project is to provide the Basque health service with an instrument with which to stratify the population in prospective way, according to their health care needs. currently, a research study is being carried out, the objective of which is to establish the validity of different models for predicting the demand for health resources and categorizing the citizens in levels according to their requirements for health care in the future. the predictive models which are being analyzed incorporate demographic, socioeconomic and medical variables as well as those relating to the previous use of health services. to develop the information further, information proceeding from other data bases is also used, such as the hospital cMDB, the annual classification of primary patients in case-mix, digitalized records of specialized care, Department of health prescriptions and census data. it is estimated that the study, which includes all the non-pediatric population,who receive care from the Basque Health Service, (Osakidetza), is estimated to be finished by the end of 2010. the conclusions of the research will enable mechanisms to be established for the stratification of the population and, thereafter, the design of specific interventions for the different patient groups, adapted to their degree of need. to successfully integrate this project in day to day practice the process will be systemized. in this way, information from the stratification of the population will be easily accessible and it will be feasible for different clinical and management groups to make use of it for the efficient carrying out of their function. Table 14: Strategic Stratification Project 1 Strati cation of the Population Flagship target Expected Impact To establish a prospective model of recurrent strati cation of the population, according to the care requirements and future demand for resources, enabling the design of speci c actions for each group, with particular emphasis in those su ering from multi-pathologies (mainly chronic patients) Operative strati cation of the Basque Population, systemized and recurring Marzo from 2011 onwards 25 Calendar – Principal milestones Jan – June 2010 June – Nov 2010 Nov 2010 – March 2011 Feb 2011 onwards Choosing Segments Requesting Data Comparative Choosing model and designing and setting up data analysis of potential and initial applica- actions bases models tion Systemization (in de nition) Using Information (in de nition) Source: own elaboration38
  • 41. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 2. Prevention and promotion interventions on the principal risk factors this strategic project aims to construct a common framework for the prevention and promotion interventions concerning the principal risk factors related to chronic illnesses. Within this framework will be grouped the various specific interventions; both those which are centrally organized (e.g. tobacco regulation), and those which are the initiative of the clinical level (e.g. Prescribe Vida Saludable- Prescribe A healthy life, prevention of type ii diabetes or the preventive actions aimed at the elderly) and those which offer evidence of being effective for their implementation in the Basque country. it also incorporates collaboration, beyond formal health services, with the rest of the government organizations (e.g. sports promotion), with patients associations and with the third sector. the key to the success of this project is the initiation of the programmes for citizens at risk. in this context it is necessary to develop a range of more sophisticated communication techniques, including new forms of communication (e.g. social marketing, education workshops, etc). An intervention example: Prescribe A healthy life (Prescribe Vida Saludable) the objective of the Prescribe A healthy life project is to optimize the promotion of physical activity, balanced diet and the giving up of tobacco in the context of primary care. it is a research-action project in which professionals of all areas, together with researchers, develop and assess innovative interventions aimed at modifying the aforementioned behaviours. it requires changes in the organization and the operating procedure of the centres involved in order to redirect their focus towards health promotion with the cooperation and the use of resources from sectors from outside the health sector. the work plan is divided into progressive phases: (1) modelling phase based on the new “healthy life Programme” in the intervention centres (2010), (2) piloting to see its feasibility and its potential effectiveness (2011-2012) and (3) dissemination of the programme and assessment of its impact on the population (2013-2015). Table 15: Strategic Project of Prevention and Promotion 2 Prevention and Promotion Interventions against the principal risk factors Flagship target Expected Impact To construct a common framework of Health Prevention and Promotion combining with the strategic lines on the principal risk factors with Prevention of the appea- innovative bottom-up pilot projects, such as, for example, the De_Plan rance and progression of project: Prevention of the progression of Type 2 diabetes in high risk chronic illnesses. For subjects between 45 and 70 years of age (approx 200,000 persons) example, in the De_Plan a reduction in the risk of developing Type 2 Diabe- tes in 58% of the popula- tion, or the reduction ofMarzo25 Calendar – Principal milestones May – June 2010 June 2010 – December 2012 tobacco demand by De nition of Updating of the strategic lines and selection of pilot projects to introducing habit kicking strategic lines be started up treatment Launch of Pilot projects Extension of successful pilot projects to in selected centres all the Primary Care centres in the Basque Country 39 Source: own elaboration
  • 42. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 3. Self-care and patient training Scientific evidence demonstrates that patients who self-manage their illness, having received support in order to be able to do so, obtain better results controlling their illness than those patients who do not carry out self-care. to achieve this goal a wide range of structured education interventions can be used. in the Basque country various measures will be applied, both in face-to-face and remote teaching, individual and group, by health professionals or istockphoto - getty images by “active patients”, with specific training to improve patients’ levels of self-control, or those of the carers when necessary. in particular, the Active Patient Model – Paziente Bizia following the methodology of the university of Stanford, will begin at the end of 2010, following a pilot programme at the end of 2010, after the formation of a group of health professionals and active patients who can begin to train other patients. Table 16: Strategic Self-Care and Education Project for the patient 3 Self-Care and education for the patient: Active Patient Pilot Project – Paziente Bizia Flagship Objective Expected Impact “Introduction of the “Chronic disease Self-Management Program” Univer- sity of Stanford”. Actions: • Experiences in the • Enabling “Master Trainers” for the training of “leaders”. main chronic illnesses • Enrolling patients and initiation of courses to these patients (6 sessions for a total of 15 hours per course). • Greater adherence • Training leaders (from amongst trained patients and health workers) • Appropriate use of to enable them to give courses to other patients. health resources Marzo 25 Calendar – Principal milestones June- July 2010 September 2010 October 2010 - July 2012 onwards June 2012 Master Training for Selection and Pilot project in the 15 trainers for training of Patients Areas of Ekialde, Extension to other patients to become Trainers Araba and areas and illnesses Eskerraldea Identi cation and piloting of other self-care and education initiatives for the patient Source: own elaboration40
  • 43. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrySTRATEGIC PROJECT 4.The setting up, by the Associations ofChronic Patients, of a Network ofActivated and Connected Patientsusing Web 2.0 technologiesAchieving a network of activated and connectedpatients, accountable for their own health andtaking responsibility for their own care when theysuffer from a chronic illness, capable of receivingand offering support to other people who findthemselves in the same situation, requires workin other areas outside the health service as well.the Patients Associations cover these other areas,aside from health, in which the chronic patient is istockphoto - getty imagesinvolved, including personal, family and social.n order to get across to these patients the principles of co-responsibility and self-empowerment which we consider to be of priority importance in the relationship with thehealth sector, and, furthermore, to extend, this idea to those who are continuously dealingwith the patients (families, carers, support professionals), one of the basic strategies isthat of supporting and strengthening the patients associations. the strategic project whichis presented below will help them to take advantage of new technologies (Web 2.0) toenable easier and more active communication between members, encouraging thesocialization of existing knowledge- not only about the illness, but also about how to leada more active and better quality life – enabling this knowledge to evolve and spread toall members openly, without limitations of time or this end, an offer of financial and technical aid has been made to the main chronicpatients and carers associations in our region, to encourage them to develop a strategyof communication and interaction for the communication and mutual support as well asknowledge dissemination using Web 2.0 technology which will favour the set up a socialnetwork between members.this initiative will be further enhanced by the setting up of a common platform for all theassociations, which will enable the breaking down of barriers between each illness, makingit easier to set up social support networks for people who are affected by similarcircumstances despite suffering from different pathologies. Synergies will also be createdbetween associations and the path will be laid open for collaborative projects in the future.the platform will enable the patient to become active, even with regard to suggestionsand feedback regarding any innovative experiences which are helpful for his or her needs,promoting a different path along which to proceed for the various agents involved (thePatients Associations themselves, the Social and education Services, and the healthSystem). these alternatives will be considered as potential pilot projects by the Departmentof health and consumer Affairs, with the aim of assessing their results in the future. Allinvolved parties will become potentially active agents in the innovation and transformationof our health system and in the relationship between other public and private areas.eventually, this common platform of networked patients will be able to link up with othernetworks which have been set up in other strategic projects such as oSAreAn, theActive Patient and certain Prevention initiatives such as De_PlAn. firstly, the patientassociations can seek support from oSAreAn, making full use of the training servicesand materials offered by this platform. Secondly, this common platform will enable thepatient groups which have been set up in the expert Patient or De_PlAn projects andwhich wish to extend their connection beyond the health system to do so via the newtechnologies. 41
  • 44. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Table 17: Strategic Project for adopting new technologies by the chronic patients associations 4 Support to the associations of chronic patients Flagship Objective Expected Impact Support chronic patient associations in the adoption and use of new communication technologies (Web 2.0) in order to improve access to information and to promote interaction and mutual support between members The creation of virtual communities of patients based on the 5-10 main associations Marzo of chronic patients in 25 Calendar – Principal Milestones the Basque Country June 2010-Sep 2010 2010 – 2011 Announcement Development of projects by the chronic patients and award of aids associations Source: own elaboration42
  • 45. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrySTRATEGIC PROJECT 5.Unified Medical Record:Osabide Globalthe project of the Shared Medical record wasput into action in the Basque health Service(osakisetza) 12 years ago by way of two strategicprojects: osabide-AP, aimed at Primary care ande-osabide for hospitals, with the objective ofeliminating all the existing barriers between theorganization of services, centres and care levelsat that time.As far as the support systems for medicalprocedures is concerned, the experience ofshared medical records in the Basque health Service (osakidetza) goes back almostfifteen years, becoming a basic tool for doctors and nurses. the degree of use variesdepending on the care area: in Primary care or emergencies it is totally integrated, inother areas it is more limited. nevertheless, in general terms, it can be said that thebalance is a very positive one.once the final phase of the process of systems renovation was achieved, both for Primaryhospital care, in 2009 the decision was taken to move towards a new generation ofmedical record systems.this new generation is seen as a leap in quality over from the existing systems, andbasically follow the following lines of work:• The elimination of all existing organizational barriers, so that all professionals involved in care share all the existing information on the patient supplied by communication mechanisms in real time.• The authorization of mechanisms of patient interaction which go beyond face-to- face consultations, (telephone consultation, email, video-conference by web-cam, etc.). 43
  • 46. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country • The setting up of proactive information systems which manage the information according to its relevance, and bring to bear elements of “intelligence” (e.g. medical alerts, warnings). currently, the system is in the initial pilot stages in three care areas: outpatients, conventional hospitalization and home hospitalization at three hospitals in the network. the plan aims to tackle progressively the different areas of care until covering all areas by the end of 2011. for each one of the areas, as with the first two, an initial pilot stage is established with a limited number of professionals. During this stage appropriate adjustments will be carried out, on the basis of its practical utilization. once validated the oSABiDe gloBAl Application will be extended to the rest of the professionals within the Basque health Service (osakidetza). the plan for 2010 is centred in its introduction into the hospitals: hospitalization at home and outpatients (already started in April), hospitalization (begun in July) and emergencies (foreseen for the end of 2010). Table 18: Strategic Project of the Unified Electronic Medical Record 5 Uni ed Medical Record: Osabide Global Flagship Objective Expected impact To create and deploy Osabide Global, a sole solution for medical records for all levels of care throughout all the network of centres which will enable professionals access patient data in the Basque Country and Universal introduction of modify it when necessary the uni ed medical record by the end of 2011, o ering an integral treatment to the patient, increasing medical Marzo precision and reducing 25 Calendar – Principal Milestones the time spent by Jan – June 2010 Jan - Sep 2011 doctors to clearing up Design of the data Extension to all centres elds to be included and for all health questions related to the and developed professionals patient’s medical record Feb – Dec 2010 Piloting • Home hospital • Hospitalitation • Outpatients • Emergencies Source: own elaboration44
  • 47. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 6. Integrated medical care this project is experimenting with different approaches to clinical integration, especially between Primary and Specialized Care. this experimentation will enable a gradual advance in a way which is compatible with the specific reality of the service organizations as well as an extension of the experiences which have proven to be more successful. it is not an attempt to define a unique model of integrated clinical working practices to be applied to all regions and centres, as, in general, the needs and possibilities of integration will be different in each case, but it does require a determined step, on all parts, to share new practices and whenever the case is presented, to universalize models which have proven to be particularly successful in certain areas or procedures. By its own nature, this process of clinical integration will be relatively slow, and for it to be successful it has to be set up by local healht care personnel and management staff, supported by senior management to maintain momentum and to add fine-tuning. Moreover, posterior efforts in this line have to take into account other levels of care, principally the centres for mental health. Table 19: Strategic Project of integrated medical care 6 Integrated medical care Flagship Objective Expected impact To explore through the experiences of the pilot projects new ways of working and organizing of the health care suppliers, integrating primary care and specialized care One third of the organizations for 2013, with integrated procedures which will allow continuousMarzo interventions which25 Calendar – Principal Milestones reduce the number of January – June 2010 June 2010- January 2011 2011 – 2012 duplicated structures and “referrals” between Organizing and procedural integration in Integration in the Bidasoa hospital and its health care provision sectors psychiatric care in centres Extension of the Bizkaia Procedural Integration in the successful models Mendebaldea local area and between Galdalkao Hospital and the Interior areaSource: own elaboration 45
  • 48. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 7. Developing sub-acute hospitals the reality of chronicity makes it increasingly necessary to establish an intermediate level of care with a lower level of technology and with a lower level of care than in a conventional hospital for acute patients, but at the same time with an integrated care capacity more developed than that of traditional Primary care centres. current medium-term stay hospitals are the perfect place for this development. therefore, a new model of sub-acute hospitals is being set up and developed which can treat the reagudization and the rehabilitation of chronic patients in a way which is more focussed on the patients’ needs and more efficient for the System. it is also the kind of hospital which is connected to the community and which can act as a centre of coordination between hospitalization and the home and which can coordinate cases and integrate care levels. Table 20: Strategic Project for the development of sub-acute hospitals 7 Development of sub-acute hospitals Flagship Objective Expected impact De nition of a model of care for chronic patients, consolidating an intermediate level of care between specialized and primary care for the speci c care of these patients Introduction of the model in mid-term stay hospitals and the set up of a new chronic hospital Marzo 25 Calendar – Principal Milestones in Alava January – May 2010 June 2010 – December 2012 Introduction of the model, especially in mid-term stay hospitals, De ning the model but with the possible consequences in local hospitals and acute hospitals Source: own elaboration46
  • 49. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 8. Definition and implementation of advanced nursing competences the challenge of better management of chronic conditions is an important opportunity for nursing, a profesion which is our setting ahs been looking for new references and functions. At the same time new regulatory changes in the training of nursing will reinforce their relative position as health care profesionals. With the aim of defining and implementing nursing roles which are better adapted to the needs of chronic patients, a multi-disciplinary work group has been set up by the Department of health and consumer Affairs and the Basque health Service (osakidetza). throughout 2010 and within the framework of action of this work group, the aim is to draw up a proposal for the development of new advanced nursing competences focussed on chronic care, to reflect on the possible framework of responsibilities, and to identify the related training needs (necessary steps previous to specific pilot projects on case management models in 2011). Table 21: Strategic Project of advanced nursing competences 8 Advanced nursing competences Flagship Objective Expected impact To de ne and develop advanced nursing competences in Osakidetza in relation to dealing with chronic patients, in particular complex chronic patients. Leverage in successful cases in other health systems (national and international) To train 300 nurses in the Basque Country in new roles up until 2013, seeking to obtain anMarzo integral level of care for25 Calendar – Principal Milestones the needs of complex May- June 2010 June – Oct 2010 October 2010-2012 From 2012 patients onwards Benchmarking and De ning model and Training and budget scenarios Extension to all role selection for piloting (centres to centres analysis be decided) Methodology based in working groups with the agents who are involvedSource: own elaboration 47
  • 50. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 9. Social and Health Services Collaboration throughout this document we have seen a series of strategies which lead to a change in the relationship with our chronic patients, which will develop from a purely biomedical vision to a holistic vision which has to take into account diagnoses, the social function and situation of the patient in order to establish an individualised plan of care by multi-disciplinary teams. this project puts into practice the integralistockphoto - getty images assessment of the patients and encompasses all the elements of the vision of this care strategy to chronicity including the socio-health aspects for the Basque population, not only through the incorporation of new resources, but also by means of the reorganization and coordination of the Health System and the Social Services, offering formulas which integrate a complete package of services for the users. the social-health service is framed within the objective of providing social-health care, as stated in the Social Service Act 12/2008, 5th December, and defined as “all care offered to people who, due to serious health problems or functional limitations and /or being at risk of social exclusion, need coordinated and stable simultaneous social and health care”. Among groups which likely to fall into this category are: elderly people who are dependant on others, disabled people, people with mental health problems (in particular those with a chronic serious illness and people with drug dependence problems), people with chronic somatic illnesses and/or invalids, people convalescing from illnesses who, despite being discharged from hospital, do not yet have sufficient autonomy for self-care, people with terminal illnesses, and other groups at risk of exclusion. the success of the project requires the involvement of all the providers of social health services and therefore, it is currently undergoing a consensus procedure with the institutions at the three levels of social service action: the Basque government, the county councils and the town halls. What is being sought is not just coordination, but a synergy resulting from the joint action of all the involved parties. in short, the three major strategic objectives which are included in the project are as follows: 1. To develop the social health services, enhancing socio-health coordination at Primary care level through interdisciplinary teams, as a guarantee of integrated care throughout the period of care, considering the home as the principal provider of care, as well as promoting and standardizing the development of socio-health resources in the three Provinces. 2. To improve the coordination of systems and structures at socio-health level, promoting the existence of a common legal framework which specifies the catalogues of social and health care, as well as drawing up a new model for the financing agreement for socio-health services. 3. To enhance system management to bring about an improvement in the levels of care, by means of training and increasing the awareness of everyone involved in socio-health coordination, as well as the implementation of a shared information system. 48
  • 51. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country the putting into action of these strategic objectives will reach fruition with the development of suitable operative Plan for each Province. Table 22: Strategic Socio-Health Collaboration Project 9 Socio-Health Collaboration Flagship Objective Expected impact To develop a framework of social and health services collabora- tion with all the social service actors (Ministry, Provincial Councils, Multi-disciplinary PC Town Hall). It will develop master guidelines to provide an integral teams with the home response to chronic patients which have simultaneous need for as the principal social and health care provider of care in 2010: 4 municipalities withMarzo integrated working, 125 Calendar – Principal Milestones hospital with an Jan – March 2010 April – May 2010 June 2010-2012 admission plan with dependence Definition of the Uniting the Joint work on specific prevention, 1 unit of socio-health framework socio-health framework lines and introduction (health vision) with the social of agreements orthogeriatrics protagonistsSource: own elaboration 49
  • 52. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 10. Financing and Contracting the beginning of the 21st government has heralded a change in the leadership of the Department of health and consumer Affairs and the arrival of a different way of understanding the Basque health System. this new vision will mean the promotion of a strategy which requires a strengthnin in the commissioning . Similarly, changes will be made in clinical management level in order to align with the new approaches. in the Basque region commissioning is carried our by the provincial health authority level; the function is not decentralised to provider units. this set of circumstances makes it an ideal moment to reflect on the usefulness of the Commissioning process, its structure and its content. this reinforcement of the commissioning process is being designed for all health care activity but for the first time specific signals are being sent to providers the contract in relation to chronic disease programmes and in relation to the need to identify approaches to integrated care . in this sense, changes have been made in the renewal of the contract of health services which include commitments, actions, and standards in chronic illness procedures which involve both primary and specialized services, incorporating commitments to home care at both levels and also in the areas of patient safety, palliative care and social and health services integration. Table 23: Strategic Project of Financing and Contracting 10 Financing and Contracting Flagship Objective Expected impact To adapt the mechanisms of financing health suppliers (Contracting Programme and Agreements), moving progressively from an activity strategy to an adjusted population and health Fully introducing a results strategy, aimed at providing care which fulfils the system of provisional objectives of the chronic illness strategy financial allocation adjusted for risk,with prioritization and focus Marzo of the health 25 Calendar – Principal Milestones expenditure, aiming it June 2009 - June 2010 - June 2011 - June 2012 - towards criteria of April 2010 Feb 2011 Feb 2012 Feb 2013 efficiency and Contracting 2010 effectiveness currently in effect Contracting 2011 Contracting 2012 Contracting 2013 and follow up phase) Source: own elaboration50
  • 53. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countryin this line, in 2010 changes have already been made to the current Programme contractModels in order to adjust them to the new plans and strategic priorities. these changeshave been structured around the General Contracting Plan for Health Services and theiradaptation for each province according to the three Provincial Purchasing Plans.furthermore, a particularly important role has been assigned to the development of actionsand measures within the framework of chronic patient care. in addition, the integrationand care continuity projects and their financing have been given priority, as well as projectsaimed at improving care quality through the use of technologies, the definition of newintegration procedures, etc. throughout this process those projects have been highlightedand prioritized which, as well as focussing on the aforementioned priorities, will involvethe defining of shared objectives by more than one organization.A mixed coordination committee made up of all the agents from the different levels oforganization involved in health care contracting has participated and will continue toparticipate both in the definition of these objectives and in their assessment. 51
  • 54. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 11. OSAREAN: Multi-Channel Service Centre the Department of health and consumer Affairs of the Basque government, through the Basque health Service (osakidetza), is supporting the setting up of a Multi-channel health Service centre (MhSc) which will increase the number of ways in which the public can interact with the health system. this project is critical from the point of view of chronic care as it will serve as a tool with which to maintain the level of low intensity constant contact which is required by chronic patients, in contrast to the sporadic high intensity contact which acute patients receive from traditional face-to-face care. the aim of the project is to use all the available channels of interaction (Web, telephone, SMS, Digitial television,…) between the citizen and the health system in order to facilitate the care procedures, porviding them with greater agility and more decision making capacity, in such a way that, interactions between the public and the health system interfere less with their personal life and work. furthermore, it will add value to the medical work, offloading administrative procedures, monitoring activities and routine check-ups, with the aim of focussing on higher value activities. finally, it will promote the involvement of the citizen with their own health and the patient with their illness using channels complementary to face-to-face, as a key strategy to improving the health results throughout the health system, converting citizens into agents of the health system. the final objective of the MhSc is to help the Basque health System to fulfil its objectives and to contribute actively in the transformation of the current Health System affording the Basque society with remote multi-channel mechanisms of health care provision through the application of it and telemedicine. it will bring the public services closer to the citizens making use of new technologies, improving efficiency in the use of resources, and by introducing demand management mechanisms which will contribute at the same time to an improvement in the quality of services provided. As far as the principal services to be provided are concerned, the MhSc will enable administrative procedures to be carried out (primary care appointment management, reminder and/or confirmation of appointments, medical certificate reports, tiS (personal health card management,…) and will make general health service information available to the users (range of services, health centre directory, night clinics and duty pharmacies). Moreover, it will foster health promotion, information and education, through the Patients Forums for the promotion of healthy lifestyles and vaccination reminders and information regarding Public health programmes. chronic patients will also receive training in the management of their illness, and remote monitoring will be promoted in order to carry out precautionary action during the phases of medical destabilization, coordination between health services will be fostered (e.g. with emergency services, access to medical data and guides and online corporative protocols). there will also be a telemedicine home care service (remote assessment systems and telemetric monitoring) for domiciliary chronic patients, multipathology patients and those with advanced or unstable pathologies. finally, the MhSc will provide Medical Advice and will enable the citizen to access information regarding his or her health (personal health file). the linguistic teleinterpretation Service has been in operation throughout the Basque health Service network (osakidetza) since february 2010, and in the near future a52
  • 55. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country contact centre will be set up to attend the public (pilot project for 50,000 citizens in Bilbao). As far as telemonitoring is concerned, there are a series of pilot projects taking place both in Primary and Specialized care: • Primary Care: Diabetes in Alava and uribe costa, cardiac insufficiency and/or ePoc in Bilbao, and ePoc the interior region. • Specialized Care: Diabetes in hospital Donostia, remote monitoring of cardiac stimulation devices in txagorritxu hospital and chronic obstructive Pulmonary disease in galdakao hospital. • other projects in the study phase with possible actions in the near future are: • remote monitoring of cardiac stimulation devices in hospital Donostia. • communication of tAo results and prescription support using Web access and SMS. • introduction of new systems of non face-to-face interaction in mental health services in gipuzkoa. Table 24: Strategic Project of Multi-Channel Service Centre11 OSAREAN: Multi-Channel Service Centre Flagship Objective Expected impact To develop a technological and organizing platform which permits multi-channel interaction with all the citizens of the Basque Coun- Deployment in the try with the health system, enabling procedures, simplifying the Basque Country of all life of the citizens and giving prestige to the work of the health the services of the professionals Multi-channel Service Centre by the middle of 2013, offering toMarzo the citizen greater25 Calendar – Principal Milestones ease of interaction with March- Nov 2010 Nov- March 2011 March- Nov 2011 Nov- March 2013 the system and an Development of improvement of the the platform and Incorporation of Deployment and efficiency in the basic deployment extension of new Progressive new services and to 400,000 basic deployment services – basis deployment of all provision of services inhabitants the planned to 1,000,000 deployment 100 services and allocation of Piloting of inhabitants tele-monitoring resourcesSource: own elaboration 53
  • 56. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country STRATEGIC PROJECT 12. Developing e-pharmacy and e-prescription the correct use of medication and its correct administration forms an integral part of the good management of chronic illnesses. this requires improving medication management, providing information and education to the user, supporting better prescribing in Primary and hospital care, as well as the process of dispensing and administration of medicines. the e-prescription involves the integration of the procedures of pharmaceutical supply (prescription, permit, dispensing and invoicing) istockphoto - getty images based on information technologies. it enables a change from the concept of the pharmacist’s prescription to the establishment of integrated pharmacotherapeutic plans, particularly relevant from the point of view of chronic illnesses due to the existence of multimorbidity, complexity and long duration of the associated pharmacological treatments. the introduction of the e-prescription is expected to have a significant effect on the population affected by chronicity to the extent that the control, the safety and the quality of the pharmacological treatment will increase. it is also expected to provide a quality prescription, to broaden the level of pharmaceutical care and to reduce administrative paperwork. furthermore, it can serve to boost the role of the citizen/patient with regard to their responsibility and autonomy and even contribute to the development of multi- disciplinary, coordinated and integrated care provision. it can also support patient self- management and education. the e-prescription is, therefore, a powerful tool which, together with others, will contribute to the achievement of the following objectives: foster the role of the citizen at the core of the health System, promote the integration and continuity of care provision, improve patient safety, boost efficiency in the use of medications, improve care for chronic patients and develop a risk stratification. the introduction of the e-prescription is currently being extended to all the Basque community. Table 25: Proyecto Estratégico de receta electrónica 12 Strategic Project of e-prescription Flagship Objective Expected impact To introduce the system of e-prescription Creating a single electronic pharmacotherapeutic record of the patient E ective introduction of encompassing all care levels, making the necessary information the e-prescription system available to each of the di erent protagonists involved and reaching integration of the prescription-dispensation throughout the Basque Country by 2013, increa- sing the safe and e cient use of medici- Marzo nes, eliminating “admi- 25 Calendar – Principal Milestones nistrative” visits to the June 2010 – Dec 2011 2012 (approx) 2013 (approx) centres and saving time and trips for citizens Extension to all the Extension to associated Development of the system Specialized Care centres, and extension to Primary centres, other doctors socio-health, residential and interoperability and Care. Initiate the and nursing centres deployment in Specialized dispensation in hospitals Care54 Source: own elaboration
  • 57. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrySTRATEGIC PROJECT 13.Setting up the Centre of Research forChronicityAll the aforementioned strategic projects willgenerate for the Basque health system a widerange of experiences for improving the treatmentof chronicity and the sustainability of the healthsystem: experiences which will be logicallyassessed and researched in order to evaluate anddemonstrate their efficiency and their capacity tobe scaled up throughout the health system.this logical analysis and assessment applied toan important number of projects accompaniedby a strategic change in the system of care forthe chronically ill will enable the Basque healthservice to become a point of international reference for knowledge generation and scientificevidence. this, in turn, will attract top class researchers capable of relating the experienceaccumulated in the Basque country to that of other countries, thereby generating anetwork of improved scientific evidence at international level concerning the treatmentand care for chronicity.the setting up of a Centre of International Excellence in Chronicity will enable innovativepractices to be identified at international level and the structured generation of scientificevidence regarding new forms of treatment for chronic illnesses by means of aninternational network of agents which will make it easier to draw more generalizedconclusions from this research as it will be carried out in different contexts.At the same time, it will be possible to benefit from the “pull effect” which this researchcapacity will have on various activity sectors related to the Biohealth and Ageing cluster,both from the point of view of generating new products related to chronic care in differentenvironments, and with innovative socio-health services.this initiative will facilitate access to state of the art knowledge and research methodologies,as well as national and international sources of funding, strengthening the establishmentof an innovative health system, capable of incorporating research into actions for resolvingchallenges over time, and prepared to generate the necessary scientific evidence toimplement these innovations within the system of publicly financed care provision. 55
  • 58. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Table 26: Strategic Project of the Chronicity Research Centre 13 Research Centre for Chronicity Flagship Objective Expected impact The establish a research centre to identify, adapt, pilot, and introduce the best practices to deal with the challenge of chronicity, generating “glocal” knowledge for innovation in organization and management and To be a an international to improve the health systems point of reference for knowledge about chronic illnesses, generating evidence that Marzo will o er support to the 25 Calendar – Principal Milestones di erent initiatives and projects related to them April – July 2010 September - October 2010 June 2012 - February 2013 Design and functions proposal for the Research Feedback process from Set up of the Research Centre stakeholders centre Source: own elaboration56
  • 59. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrySTRATEGIC PROJECT 14.Innovation on the part of the medicalprofessionSeveral of the aforementioned projects arestrategies conceived from top to bottom as linesof work which are necessarily uniform andstandardized for all the Basque country. (e.g.medical records).however, other changes invite research-actionwhich is led by doctors, nurses and managers atlocal level. in many senses, the necessary changeis both a medical and an organizational challengeas well as one which affects leadership and themanagement model. the new paradigm which ispresented requires a change in the organizationwith the consent and leadership of the professionals particular, this line of strategic work will encourage local experimentation, creatingconditions for the base to be able to look for “their” best solutions. A way of activatinglocal initiative is to provide resources and facilities so that local teams can start pilot trialsin system management. the managers, the health professionals and the end users arethe parties which should receive support to have the organizing capacity sufficient toimprove their areas of involvement.these conditions are being achieved through the various mechanisms which will beproviding bigger and better resources over time.the internal processes of research financing have been activated, both commissionedand non-commissioned, in order to promote local initiative in research actions. thephilosophy is to promote innovation in health care organization to the same extent asbiomedical innovation, fostering experimentation with a research perspective. this is thereason why, since the year 2010 we have defined a new research modality named withthe dual scientific and active term action-research. this is a pioneering modality inSpain and the aim is to establish the importance that this strategic change is affordingthe promotion of innovative attitudes at the heart of clinical teams. the projects presentedto the 2010 study review will be assessed by a specially selected committee which willseek to support the base initiatives, whenever these are aligned with the strategic objectivesand have the appropriate experimental organization and design.for this level of rigorous research to be compatible with a focus on action, a methodologicalsupport and research-Action project integration team has already been set up, whichwill support the different teams of medical professionals so that their results can beassessed, shared and systematized. this team will be made up of osakidetza personnel,with a stipulated dedication to this function, forming a functional action-resaerch unit. toensure a level of excellence and proficiency in research methodology, both osteba ando+Berri, will make sure the team is continually updated in material, promoting its increasein capabilities and competence.thus, by means of the projects which the Service organizations are committed to carryout in the quality Annexes of the commissioning Programme, the initiatives of the clinicalpersonnel are being aligned with those of the service organizations, having an impact onthe financial resources which these could end up receiving. this route is particularlyuseful to identify the projects in healht care innovation which are of most interest to thedifferent service organizations and which are likely to be rewarded with successive researchfunding in research action. 57
  • 60. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country in addition, a support procedure has been designed for developing, assessing and extending to other local areas those projects which prove to be cost-effective in the Basque system. this process will be carried out in pilot form in 2011 with the projects which come to an end during that year and will be made definitively official from 2012. Table 27:Strategic Project for innovation on the part of medical professionals 14 Innovation from the medical professions Flagship Objective Expected Impact To design the process, the tools and the leaders with the aim of facilitating and promoting emerging innovation by means of pilot “bottom up”projects, and to ensure its sustainability and Generation of 15-25 extension throughout the Basque Country, when the desired innovation projects a results are reached year and the extension of those which produce health results and Marzo sustainability (it is 25 Calendar – Principal Milestones May 2010 - hoped that 90% will June 2010 2010 – 2011 produce results) Innovation Pilot projects 2010: Detailed defini- Learning tion of the process and tools Carrying out and monitoring the official process - 2011 Source: own elaboration58
  • 61. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country 59
  • 62. Achievingchange: AnImplementationstrategy
  • 63. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country accepTing coMple XiT y how do we advance to a more proactive health system? how do we educate patients to be active participants in the management of their illness? how do we improve clinical integration between primary and hospital care? how can we make a qualitative leap in the use of technologies and Web 2.0 applications in benefit of the patients? All the aforementioned strategic projects have many aspects in common, but one in particular: their complexity. the fact is that many of the transformative projects included in this strategic framework require a number of complex interventions in numerous areas of activity; there is no “magic wand” to carry this out. it is necessary to work through many levers of change; these numerous levers are represented by the 14 strategic projects described above. changing from the current system to one which is capable of providing excellent care to chronic patients cannot be achieved without a progressive and integral transformation of the system of care provision. this is one of the clear lessons from implementation practice in this and in other areas. the temptation of the corporate leaders may be to want to accelerate the pace of these transformations by means of direct and regulatory structural changes. however, this Strategy on chronic care is riddled with complex changes and as a consequence its projects cannot be merely imposed in an interventionist fashion: to achieve our goal it is necessary to follow a path which is less interventionist and more emergent. in planning terms, to identify for our context a successful balance of a traditional planning approach with a more emergent end learning approach. A great number of the Strategic Projects in this document require new relationships and collaborations between different actors in the health system, actors which up to now have been living in a silo structure. To p- d oW n a n d boT To M - u p there is always tension between an excessively interventionist or top management approach and local decision making capacity. in the past, in the Basque country there has been too much of the former and not enough of the latter. in the case of this Strategy the aim is to find a better balance in decision making as it is our opinion that local managers and professionals will very often find more innovative solutions than central planners. Many directors may think it ingenuous not to exercise a control of even greater imposition during these times of economic crisis with the objective of rapidly imposing the changes described in this text as, among other things, these changes open new avenues to enhance the sustainability of the health system and hence their urgency. however, all the scientific and management evidence indicates that the naïve policy would be just the contrary: trying to impose this system transformation. in the implementation of the Strategy for the Management of chronicity in the Basque country a new balance is sought developing a more distributed style of leadership: neither a purely interventionist focus “top down” and more development focussed “bottom up” style would appear to be insufficient to act alone as motors of change: • on the one hand, an entirely interventionist focus “top down” often encounters difficulties to encourage clinical leadership, something essential for most of the changes explained above. this may make the adaptation of the interventions to the local reality impossible and, generally speaking, leads to failure in their implementation, either because the interventions are not taken onboard in the day to day clinicalistockphoto - getty images 61
  • 64. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country procedures or because they are not suitable to the specific needs of the patients and health professionals at a local level. • on the other hand, although a purely developmental approach, via a “bottom up” action, one may be able to bring about successful experiences driven by some health care professionals at a particular health centre, there will be a lack of support, tools, or formal mechanisms to extend the experience to a wider area; thereby generating “islands of excellence” which are never scaled up and finally become obsolete or may disappear along with its creator. furthermore, even in the cases in which some scaling up is achieved, the focus soon stumbles due to the absence of a strategic direction, something which tends to make initiatives incompatible or redundant. for these reasons, to implement the Basque Strategy on chronic care, the tactical decision taken has been to systematically combine both focuses: adopting a clear strategic direction, which is filtered simultaneously through an emergent process originating from the front line of health professionals and managers as they bring about the changes they seek. this requires a living strategy that evolves and emerges, so that the focus of the implementation is also a living process which will progress as the lessons learned from changes (in the Basque country and elsewhere) are assimilated. Table 28: The need to combine strategic direction with medical and managerial commitment Innovation and change must combine clear strategic direction with the commitment of the first line of doctors and managers Interventionism is not enough Development focus is not enough Status Quo New way of Need to change integrated working is perceived in the health sector Leadership Implemented by Top management Clear and energy middle management create a Plan direction for innovation, implementation The plan is presented New strategy Extension and extension and commitment is sought New vision mechanisms Not acceptable for Doctors Does not achieve scale, nor supports nor expands No encouragement for local successful interventions leadership and no adaptation to local conditions Does not create a common Success is acquired through direction with which to galvanize the combination of both focuses all the energy Source: own elaboration Top-down focus – A Clear Strategic Direction the proposed change requires clear directions from top management and the setting up of a playing field suitable for it to take place, one which provides support and the tools for its undertaking and the objective and standardized measurement for its progress. to this end the first components are a vision and a list of common aspirations. it is necessary to make absolutely clear what the vision is and what goal is aspired to through the change;62
  • 65. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrya vision and an aspiration which evolve and gather the knowledge from the organization,but at the same time are clearly communicated and shared by the executive managementlevel, so that there is no doubt about the direction being taken and no opportunity is lostto underline its the chronic Patients Strategy the vision consists in transforming the system so as tobe able to provide an excellent level of care for chronic patients as well as for acutepatients; as an aspiration, a common target has been set in terms of the number ofpatients in each stage of their illness who will receive the new type of care which willadapt to his or her needs as chronic patients. this aspiration makes the change tangible,making it a real transformation for health professionals, patients, managers and catalysesthe transformation as specific interventions are adapted to the results of the changesinspired by health professionals and the resulting scientific evidence.furthermore, certain basic rules of play have to be laid out and shared between managersand health professionals, these have to be the same for everyone, and be oriented to thevision defined above and adhered to without exception. in this case, the ground rulesconsist in results-based financing which promotes the use of the most efficient and bestadapted resources for each case, and the choice of interventions according to the criteriaof the scientific evidence.Table 29: Aspirations of the Chronic Illness StrategyThe vision can be transformed into tangible aspirations for the period up until 2013 Aspiration 2013 Nº of patients with new care Case 6,000 management Care 35,000 management Support for self-management 35,000 Prevention 40,000 PromotionSource: own elaborationAt the same time, it is essential to provide support from the top, with the necessarytechnological, technical and organizational tools for the administrators and health workersfor them to make the vision a reality. in the chronic Patients Strategy the tools aretechnology (unified Medical record, Multi-channel Service centre, e-prescription),methodological support for innovations at the grass-root level ( providers ), and a populationbased approach understandable by health care professionals and managers ( populationstratification to enable “targeting” of interventions). 63
  • 66. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country finally, the last task to be carried out by top management is that of monitoring progress: a transparent tracking in relation to the shared aspirations and indicators, and monitoring which will establish unequivocally if the targets are being achieved or not at each of the levels, with the aim of supporting and expanding measures which work and abandoning those which do not. Bottom-up focus – The change from local health professionals and managers the agent change is not the corporate leadership, though it is essential that these create the conditions for the change to take place at the operational level. eventually, the objective of this Strategy is to set up more innovative health systems at a local level, and at an operational level (micro-systems). it is at this level in which the real agents of change can be found, and in which the interactions take place between the patient and the health professionals: the level at which the service is provided. therefore the bottom-up focus, complementary to the top-down focus, has to give autonomy and space to the local health professionals and managers so that they can improve their working practices and the level of service they provide to chronic patients. this requires fostering change and giving the necessary support to those who try to implement it. the first part of the bottom-up focus implies giving freedom and “room to manoeuvre” to the health professionals and managers so that they can reach the objectives in the most appropriate way according to their respective service organizations and circumstances. to achieve this, it is necessary that the health professionals and managers are given total support, fostering continuous improvement in their work; giving them responsibility to change the way things are done and giving them the time to analyze and experiment, which involves giving access to management information so that they can measure and assess their own activity and reach conclusions whether it is effective or not. But this support cannot be given successfully without providing both health professionals and managers with the training, the capacity and the responsibility of operating in this kind of environment. this distributed leadership requires being able to support people who manage with a different kind of mentality to that which is usually found in the leadership hierarchy. to this end training is being offered to 150 managers and directors of the service organizations, training which will provide them with the tools and a clear mandate to work in this fashion. finally, the most important piece of the “bottom-up” model, which converts the aforementioned strategies into reality, is the process of innovation emerging from health professionals, which allows the energy for improvement and innovation generated by the managers and doctors to be channelled and focused. there are presently more than 30 bottom-up demonstrator sites activated seeking with this approach. Creating the conditions to innovate from bottom-up: Specifically the actions which are being carried to achieve bottom-up advances are the following: • to promote research in health services to bring it to the level of bioscience research. • to create an organization whose function is to support this emerging process of research/innovation in health services (fundación o Berri). • to offer specific training to 150 managers of service organizations in order to give them the tools and the clear mandate to operate in the desired fashion. Distributed leadership, clearly different to the classic hierarchal leadership, requires training for managers and health professionals so they can acquire new capabilities with which to develop their new responsibilities in an environment of this kind. there are several lines of training opened for these groups.64
  • 67. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country• to launch ambitious research grants from the Department of health and the commissioning process for 2010 with the aim of offering incentives for local experimentation in health service innovation. the ideas which are selected will receive methodological support (e.g. research methodology, system processes), procedural (e.g. follow-up, breaking barriers) and financial support so as to fund them. the research methodology will be action-research, to a sufficient scale to be able to underwrite their effectiveness.• from these trials a connection will be made, both face-to-face and remotely, with the various innovative micro-systems with a view to disseminating learning as quickly possible.• to develop a rigorous assessment of the innovative micro-systems and to select those which demonstrate effectiveness in the context of the Basque country in order to be able to extend them throughout the system. it is important to note that the innovative micro-systems are emedded within a wider health system. they are not isolated islands. their lessons will be disseminated to the rest of the system in an organized fashion in order to improve the entire Basque health System.• to continually align these processes at a local level with the general strategy of the Department of health and osakidetza. the idea is to develop numerous micro-systems capable of providing a level of care which is more integrated and more proactive. ¢ ¢ ¢in conclusion, the Basque health System is embarking upon a broad transformation inorder to respond to the challenge and the opportunity presented by chronic patients.this transformation is not an option, but, in fact, is a necessity in order to contribute tothe sustainability of the System and to be able to provide Basque citizens with the levelof care and service they need and deserve.the achievement of this change is a mid-term challenge which is going to require a clearstrategic direction, but, above all, the commitment, the energy and the innovation of thesystem professionals and the citizens who participate in it as patients and as carers.Working together, a change will be set in motion in the mid term which will take time toreach fulfilment, but once started, with the participation and the commitment of all theinvolved parties will be unstoppable. this will also enable the Basque health System tobe able to prepare for the needs of the future, contributing to financial sustainability andoffering the citizens and patients the best possible health results, better satisfaction andquality of life and a service which is best adapted to meet their needs. 65
  • 68. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country Index of Tables and Figures Ta b l e s table 1. list of possible chronic illnesses and their characteristics table 2. chronicity in the Basque country table 3. change in the prevalence of diabetes and cardiovascular disease in the Basque country table 4. illustration of the predicted change in chronic illnesses at world level. – example Diabetes table 5. Differences in the key success characteristics and factors in relation to chronic and acute interventions table 6. Principal ideas of the Aicc model table 7. interventions with evidence and examples of health systems where some of these have been implemented table 8. A basically reactive system table 9. complementing the level of excellence in acute care table 10. how the system could change for the patients table 11. expected results from the chronic illness Strategy table 12. Strategic Policies table 13. illustration of a possible pyramid of population stratification table 14. example of prevention intervention table 15. example of patient awareness and accountability intervention table 16. illustration of continuous care table 17. illustration of intervention adaptation table 18. Strategic Projects within the chronic illness Strategy table 19. Strategic Stratification Project table 20. Strategic Project of Prevention and Promotion table 21. Strategic Self-care and education Project for the patient table 22. Strategic Self-care and education Project for the patient table 23. Strategic Project of the unified Medical record table 24. Strategic Project of integrated medical care table 25. Strategic Project for adopting new technologies by the chronic patients associations table 26. Strategic Project of advanced nursing competences table 27. Strategic Socio-health collaboration Project66
  • 69. A StrAtegy for tAckling the chAllenge of chronicity in the BASque countrytable 28. Strategic Project of financing and contractingtable 29. Strategic Project of Multi-channel Service centretable 30. Strategic Project of e-prescriptiontable 31. Strategic Project of the chronicity research centretable 32. Strategic Project for innovation on the part of medical professionalstable 33. integrated vision of the expected impact of the strategic projectstable 34. the need to combine strategic direction with medical and management commitmentFiguresfigure 1. Prevalence (%) of chronic problems according to age and sexfigure 2. Distribution of the population aged over 65 according to the number of chronic problemsfigure 3. Distribution of patients according to the number of chronic illness by agefigure 4. Main medical conditions appearing in patients with multimorbidity according to the primary care diagnosisfigure 5. change in the percentage of persons with chronic problems between 1997 and 2007 according to their agefigure 6 change in the prevalence of diabetes and cardiovascular disease in the Basque countryfigure 7. number (and prevalence) of chronic patients over the age of 18 suffering from the principal pathologiesfigure 8. Prevalence of the principal pathologies by age groupsfigure 9. the care Model for chronic Patientsfigure 10. the innovative care Model for chronic Patientsfigure 11. extended kaiser’s Pyramidfigure 12. new model for the Basque health Systemfigure 13. Strategic diagram 67
  • 70. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country for more information regarding the general strategy and specific projects, please visit our web page 69