Improving Primary care for patients
with chronic illness:
the Tuscan experience
Daniela Scaramuccia, Tuscany Health Counci...
The Tuscan Healthcare System: some data
• 3,7 millions inhabitants
• 6.300 millions € for healthcare spending in 2009:
5% ...
12 Local
Health
Authorities
5 Teaching
Hospitals
The Tuscan Healthcare System
Fondazion
e
Monasteri
o
Chronic diseases
From the second half of the 20° century:
Reduction of the
morbility and mortality
of infective diseases
I...
Better health
 
  
Responsiveness
     
Fair financing
(World Health Organisation 2000)
Which is the mission of regional p...
6
Financial sustainability
Growing health needs
(epidemiological evolution)
Economic situation
(GDP e global crisis)
Shari...
77
Does Tuscany
health system has
resources that
can be
reallocated?
Yes!
7% of the
financial budget
8
From traditional healthcare to proactive healthcare
Traditional healthcare:
The healthcare system acts only
when the chr...
Data
collection
and
information
production
for
management
support
decision
systems
Proactive
healthcare
Equality
and equit...
Data collection
and
information
production for
management
support
decision
systems:
Electronic
health record
Rapid and
com...
1111
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision...
1212
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision...
13
2008 - 2010
STRATEGIC HEALTH PLAN
A PLAN FOR HEALTH
THE PROACTIVE
HEALTHCARE
1414
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision...
1515
- Based on physical exercise programmes
- Adressed to citizens affected by stabilized chronic
diseases and focused on...
16
Population involved in APA >65 x 1.000 population - 2009
4,31
14,98 14,88
11,93
21,11
21,74
13,16
22,27
7,23
10,31
18,2...
1717
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision...
1818
Self-Management Support
• Emphasize the patient's central role.
• Effective self-management support
strategies includ...
1919
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision...
2020
Delivery System Design
• Define roles and distribute tasks among
team members.
• Separate acute care from
the planned...
21
• Successful chronic care interventions require increased
clinical involvement of the non-physician
members of the care...
2222
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision...
2323
Decision Support
• Embed evidence-based guidelines
into daily clinical practice.
• Share guidelines and information
w...
2424
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision...
2525
Clinical Information Systems
• The crucial factor in improving chronic illness care is
a clinical database (electroni...
2626
GPs and other health professionals organized in
groups to care for chronic patients with a proactive
approach (Chroni...
27
goals to achieve and measures used at
regional and local level:
reduce the rate of
avoidable Chronic
hospitalizations
(...
28
From 2006, the rewarding system of the Tuscan
Health Authorities CEOs is connected to the
performance evaluation system...
29
reduce the rate of avoidable Chronic
hospitalizations
30
C11a.1.1 Hospitalization rate for heart failure per
100.000 residents (age selection 50-74)
(2009)
31
Azienda di residenza 1 2 3 4 5 6 7 8
Totale
complessivo
I D ricoverati
Totale
complessivo
ricoveri
(numeratore
TO globa...
32
Improve performance in the process care.
33
C11a.1.2 % of residents with heart failure with at least one
creatinine, sodium and potassium screening.
(2008)
34
Disseminate APA programms
Population involved in APA >65 x 1.000
inhabitants
2009
4,31
14,98 14,88
11,93
21,11
21,74
13,16
22,27
7,23
10,31
18,24
18...
36
reduce variations due to social economics
conditions
37
38
Strengthening the citizens role
citizens’ survey…to evaluate GP…
The last time you went to your GP were you happy about how
he involved you in the decisio...
Thank you for your attention
and
Welcome to Tuscany!
All the data of the Tuscan Performance
System are available on the we...
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Improving Primary care for patients with chronic illness:

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  • Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level.
    Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
    Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec; 20(6):64-78.
  • Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level.
    Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
    Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec; 20(6):64-78.
  • Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level.
    Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
    Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec; 20(6):64-78.
  • Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level.
    Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
    Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec; 20(6):64-78.
  • Let’s look at each of the elements in a little more detail:
    Self-Management support: Empower and prepare patients to manage their health and health care.
    Emphasize the patient’s central role in managing their health. Providers reinforce the patient's active and central role in managing their illness.
    Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving, and follow-up. Evidence now strongly suggests that to achieve optimal outcomes in most chronic illness, we must improve the patients ability and interest in managing their own condition. The best tested strategy to support self-management employs the 5A’s.
    Assessment includes not only knowledge but beliefs and behavior. (Knowledge isn’t enough to change behavior. We need to understand more about what patients value and what they do.)
    Advice needs to be linked to scientific evidence, not provider biases.
    Agree on goals that are important to patients and actions to reach them.
    Assist by identifying barriers and problem-solving to deal with them.
    Arrange a specific follow-up plan including utilizing internal and community resources to provide ongoing self-management support to patients.
    One example of an effective program based in the community is the Chronic-Disease Self-Management Program developed by Stanford. It is a six-week scripted curriculum delivered by lay people with chronic illness.
    Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care, 1999; 37(1):5-14.
  • Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level.
    Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
    Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec; 20(6):64-78.
  • Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support.
    Delivery system design is where we all work everyday--(WHO is there and WHAT do they do to contribute to good quality care. This is about HOW we interact with patients.)
    Most successful chronic care interventions involve increased clinical involvement of the non-physician members of the care team. We are talking about actually having a team who discusses the work they do, how they are going to do it, and how to improve on it. Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting Population-Based Care Into Practice: Real Option or Rhetoric? J Am Board Fam Pract. 1998; 11(2):116-26.
    Planned interactions have an agenda, like a routine physical or a prenatal visit. Planned visits can be either 1:1 or in groups. We can use a registry and tools to help set the agenda and not leave out critical parts of the care. McCulloch et al. Effective Clinical Practice 1998; 1:12-22 and Disease Management 2000; 3(2):75-82
    Patients with complex needs, or engaged in an acute transition or exacerbation, often benefit from more intensive attention. The use of a clinical case or care manager, usually a nurse or a pharmacist, has been shown to be effective in diabetes, CHF, depression, and other illnesses.
    Follow-up is not left to chance. Better outcomes in chronic illness care are due to proactive follow-up by the health care team. In real estate, they say, Location, Location, Location. In chronic illness, it is Follow-up, Follow-up, Follow-up. Support for telephone follow-up: Nurses increase exercise in elderly primary care pts using phone calls: Journal of Geront: Medical Sciences 2002 vol 57A no 11 M733-M740.
    Piette et al. Impact of automated phone calls and nurse calls on diabetes in the VA, Diabetes Care 2001; 24:202 (better HbA1c, more lipid testing, fewer sx, better satisfaction)
    Patients should be routinely asked to “teach back” to check comprehension and if they are comfortable with the plan. Providers need to check in with patients to make sure that the interaction style is compatible with their cultural norms, values, and beliefs.
  • Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level.
    Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
    Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec; 20(6):64-78.
  • Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences.
    Decision support begins, but cannot end, with the dissemination of evidence-based guidelines. Distribution of guidelines alone has minimal impact. What does work is the integration of guidelines into the flow of clinical decision making.
    We need to not only possess guidelines, but we must get them off the shelf or the computer screen and use them in decision making.
    Grimshaw & Russell Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342:1317
    Our typical way of interacting with specialists is to refer a patient and hope to get a letter back. Some examples include shared care, real-time consultation, and email exchanges
    Quinn et al. Overcoming turf battles: developing a pragmatic, collaborative model to improve glycemic control in patients with diabetes. Jt Comm J Qual Improv 2001; 27:255
    Katon et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995 Apr 5; 273(13):1026-31
    McCulloch DK, Price M, Hindmarsh M, Wagner E. Improvement in Diabetes Care Using an Integrated Population-based approach in a Primary Care Setting. Disease Management 2000; 3(2):75-82.
    Providers and care teams benefit from problem or case-based learning, academic detailing or modeling by expert providers.
    Another thing we can do is to inform patients of guidelines pertinent to their care so they understand why a particular test, procedure, or screening is being performed.
  • Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions the practice must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level.
    Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is the most visible part of care to the patient, followed by delivery system design. They know what kind of appointments they get and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.
    Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec; 20(6):64-78.
  • Clinical information system: Organize patient and population data to facilitate efficient and effective care.
    The crucial factor in improving chronic illness care is a clinical database that has the critical information that one needs to have a productive interaction (a registry). Even in the absence of a full electronic medical record (EMR), many registries can perform all the functions shown on the slide. Conversely, some EMRs may not be able to perform these functions so practices should be careful what information systems they employ to manage their patients’ care.
  • Improving Primary care for patients with chronic illness:

    1. 1. Improving Primary care for patients with chronic illness: the Tuscan experience Daniela Scaramuccia, Tuscany Health Councillor Sabina Nuti, Prof. Scuola Superiore Sant’Anna Gavino Maciocco, Prof. University of Florence 31 agosto 2010
    2. 2. The Tuscan Healthcare System: some data • 3,7 millions inhabitants • 6.300 millions € for healthcare spending in 2009: 5% prevention 43% hospitals services 52% primary care • 17 Public Health Authorities: 12 Local Health Authorities and 5 Teaching Hospitals organized in three Network “Area Vasta”: • North West Area Vasta: 2 T.H. and 5 L.H.A. • Center Area Vasta: 2 T.H. and 4 L.H.A. • South East Area Vasta: 1 T.H. and 3 L.H.A. • 51.000 employees • 2.940 GPs • 14.000 private and public hospital beds (3,8 per 1.000 inhabitants) [2009]
    3. 3. 12 Local Health Authorities 5 Teaching Hospitals The Tuscan Healthcare System Fondazion e Monasteri o
    4. 4. Chronic diseases From the second half of the 20° century: Reduction of the morbility and mortality of infective diseases Increase of the chronic diseases prevalence The management of the increasing chronic diseases prevalence is one of the most important healthcare problems to deal with. (Tuscany Strategic Health Plan PSR 2008-2010, p. 34)
    5. 5. Better health      Responsiveness       Fair financing (World Health Organisation 2000) Which is the mission of regional public healthcare systems?
    6. 6. 6 Financial sustainability Growing health needs (epidemiological evolution) Economic situation (GDP e global crisis) Sharing of ethical values (equity) Growing of production costs (new tecnologies) Defining prioritiesDefining priorities Manage variationManage variation Resources allocation andResources allocation and reallocationreallocation …… the problemthe problem is not “if” butis not “if” but HOWHOW to do it!to do it! The challenge:
    7. 7. 77 Does Tuscany health system has resources that can be reallocated? Yes! 7% of the financial budget
    8. 8. 8 From traditional healthcare to proactive healthcare Traditional healthcare: The healthcare system acts only when the chronic patient worsens becoming acute. Proactive healthcare: The patients’ needs are taken into account before the disease worsening and possibly before disease onset, getting better health conditions for the population Chronic diseases are not well treated and prevention as well as risk factors are not taken into account The healthcare system is able to manage chronic diseases and to be effective in facing the acute diseases onset. Where Tuscany wants to invest?
    9. 9. Data collection and information production for management support decision systems Proactive healthcare Equality and equity Resource productivity and appropriate allocation within the system Quality of care Humanizati on: health care through the patient’s eyes Population health and system sustainability Strategic map of Tuscan Regional Health Plan (PSR)
    10. 10. Data collection and information production for management support decision systems: Electronic health record Rapid and complete access to data Proactive healthcare: Chronic care model Equality and equity: Waiting lists for surgical interventions Hospitalization rate considering education level Resource productivity and appropriate allocation within the system: Hospitals Primary Care Services Pharmaceuticals Quality of care: Healthcare pathways Clinical risk Neonatal Screenings Humanization: health care through the patient’s eyes Satisfaction, communication and pain control Population health and system sustainability: Expenditures control Performance control Outcome Indicators Strategic map of Tuscan PSR: scheduled actions for the year 2010 • Improving Performance • Investiments: Healthcare and economic growth
    11. 11. 1111 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care ModelChronic Care Model Improved Outcomes
    12. 12. 1212 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care ModelChronic Care Model Improved Outcomes
    13. 13. 13 2008 - 2010 STRATEGIC HEALTH PLAN A PLAN FOR HEALTH THE PROACTIVE HEALTHCARE
    14. 14. 1414 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care ModelChronic Care Model Improved Outcomes
    15. 15. 1515 - Based on physical exercise programmes - Adressed to citizens affected by stabilized chronic diseases and focused on lifestyle change for secondary and tertiary disability prevention - Organised by groups - Concentrating on health and not on illness - Involving Local Authorities - Not taking place in healthcare services Adapted Physical Activities for elderly people (APA)
    16. 16. 16 Population involved in APA >65 x 1.000 population - 2009 4,31 14,98 14,88 11,93 21,11 21,74 13,16 22,27 7,23 10,31 18,24 18,57 0 5 10 15 20 25 30 USL 1 USL 2 USL 3 USL 4 USL 5 USL 6 USL 7 USL 8 USL 9 USL10 USL 11 USL 12 Toscana Regional target 2009: 20 per 1.000. 90,49
    17. 17. 1717 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care ModelChronic Care Model Improved Outcomes
    18. 18. 1818 Self-Management Support • Emphasize the patient's central role. • Effective self-management support strategies include assessment, goal- setting, action planning, problem-solving, and follow-up. TRAINING > NURSES COURSE > COUNSELLING & SELF-MANAGEMENT SUPPORT
    19. 19. 1919 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care ModelChronic Care Model Improved Outcomes
    20. 20. 2020 Delivery System Design • Define roles and distribute tasks among team members. • Separate acute care from the planned management of chronic conditions. doctors nurses CONSENSUS CONFERENCE
    21. 21. 21 • Successful chronic care interventions require increased clinical involvement of the non-physician members of the care team. We are talking about actually having a team who discusses the work they do, how they are going to do it, and how to improve on it. • Planned interactions must have an agenda, like a routine immunization or a prenatal visit. • Follow-up should not left to chance. Better outcomes in chronic illness care are due to proactive follow-up by the health care team.
    22. 22. 2222 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care ModelChronic Care Model Improved Outcomes
    23. 23. 2323 Decision Support • Embed evidence-based guidelines into daily clinical practice. • Share guidelines and information with patients. Regional Health Council Evidence-based guidelines > 5 chronic disease DISSEMINATION - TRAINING
    24. 24. 2424 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care ModelChronic Care Model Improved Outcomes
    25. 25. 2525 Clinical Information Systems • The crucial factor in improving chronic illness care is a clinical database (electronic medical record) that collects the critical information that one needs to make a disease registry. – Provide reminders for providers and patients. – Identify relevant patient subpopulations for proactive care. – Facilitate individual patient care planning. – Share information with providers and patients. – Monitor performance of team and system. Regional Health Agency MaCro - List of indicators – Prevalence of chronic disease – Adhesion level of practices to clinical guidelines
    26. 26. 2626 GPs and other health professionals organized in groups to care for chronic patients with a proactive approach (Chronic Care Model) Pilot phase January 2010 11 Healthcare • 56 groups • 497 GPs •112 Nurses • 618.969 Patients MITO project– 1 Healthcare • 4 policlinics • 166 GPs • 175.000 Patients Extention phase October 2010 Other groups are expected to be involved • 31 groups • 301 GPs • 62 Nurses • 337.213 Patients
    27. 27. 27 goals to achieve and measures used at regional and local level: reduce the rate of avoidable Chronic hospitalizations (age selection 50-74) Improve process care for chronic desease Disseminate APA programms reduce variations due to social economics conditionsStrengthening the citizens role
    28. 28. 28 From 2006, the rewarding system of the Tuscan Health Authorities CEOs is connected to the performance evaluation system including their capacity to achieve specific goals regarding the application of the chronic care model Targets are differentiated for each Health Authorities, according to the level of performance. During the year MeS Lab provides a quarterly monitoring of the targets to verify them timely and systematically, supporting the periodic meeting between the Regional Councillor and each Health Authority CEO. The rewarding system in 2010 involves also the MMG participating to the Chronic Care Programme.
    29. 29. 29 reduce the rate of avoidable Chronic hospitalizations
    30. 30. 30 C11a.1.1 Hospitalization rate for heart failure per 100.000 residents (age selection 50-74) (2009)
    31. 31. 31 Azienda di residenza 1 2 3 4 5 6 7 8 Totale complessivo I D ricoverati Totale complessivo ricoveri (numeratore TO globale) TOT I D che hanno subito alemno un re- ricovero % I D re- ricoverati su tot I D ricoverati AUSL 1 MC 486 50 4 4 1 545 619 59 10,83 AUSL 2 LU 275 32 2 2 311 353 36 11,58 AUSL 3 PT 466 49 16 1 3 535 631 69 12,90 AUSL 4 PO 384 43 14 3 1 1 446 537 62 13,90 AUSL 5 PI + AOUP 740 79 23 3 845 979 105 12,43 AUSL 6 LI 749 87 18 7 2 1 864 1022 115 13,31 AUSL 7 SI + AOUS 764 108 11 11 4 3 901 1095 137 15,21 AUSL 8 AR 772 113 19 5 3 912 1093 140 15,35 AUSL 9 GR 421 40 5 4 1 471 538 50 10,62 AUSL 10 FI + AOUC 2256 318 69 20 7 4 1 2675 3245 419 15,66 AUSL 11 EM 531 67 14 5 3 1 1 622 755 91 14,63 AUSL 12 VI 230 34 4 1 1 270 319 40 14,81 Toscana 8074 1020 199 66 22 12 3 1 9397 11186 1323 14,08 N ricoveri nell'anno 2009 per lo stesso I D residente Where we can act: Heart failure re-admissions within one year 2009 N of admissions for the same ID LHAs
    32. 32. 32 Improve performance in the process care.
    33. 33. 33 C11a.1.2 % of residents with heart failure with at least one creatinine, sodium and potassium screening. (2008)
    34. 34. 34 Disseminate APA programms
    35. 35. Population involved in APA >65 x 1.000 inhabitants 2009 4,31 14,98 14,88 11,93 21,11 21,74 13,16 22,27 7,23 10,31 18,24 18,57 0 5 10 15 20 25 30 USL 1 USL 2 USL 3 USL 4 USL 5 USL 6 USL 7 USL 8 USL 9 USL10 USL 11 USL 12 Toscana Obiettivo regionale 2009: 20 90,49
    36. 36. 36 reduce variations due to social economics conditions
    37. 37. 37
    38. 38. 38 Strengthening the citizens role
    39. 39. citizens’ survey…to evaluate GP… The last time you went to your GP were you happy about how he involved you in the decisions regarding your health ( referrals, exams..pharmaceutical prescriptions…) 7,28 6,83 10,58 7,93 6,61 8,17 5,90 6,51 8,39 7,48 91,72 90,16 93,17 86,39 90,34 91,07 91,06 90,63 90,78 90,04 9,06 7,80 90,56 89,93 88,27 0% 20% 40% 60% 80% 100% AUSL 1 (MC) AUSL 2 (LU) AUSL 3 (PT) AUSL 4 (PO) AUSL 5 (PI) AUSL 6 (LI) AUSL 7 (SI) AUSL 8 (AR) AUSL 9 (GR) AUSL 10 (FI) AUSL 11 (EM) AUSL 12 (VI) REGIONE No Si, ma solo in parte Si, completamente
    40. 40. Thank you for your attention and Welcome to Tuscany! All the data of the Tuscan Performance System are available on the web site: http://85.18.244.220/toscana/
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