Basis for a Social and Health Integrated Care
Plan for Catalonia:
PIAISSPIAISS
The journey from a Chronic Care Program tow...
Session structure
• A new Health Plan and the introduction
of a new STORY
• Chronicity Prevention and Care
Program: the “j...
The Spanish National Healthcare System
• NHS funded by taxes
• Decentralized to regional autonomies
• Universal coverage
•...
Catalan Healthcare System: some basic features
• Area: 32,106 km2
• Population: 7,611,711 inhabitants. 17% over 65 y.
(exp...
Public System Network:
• 369 Primary Care Teams
(827 local health centers)
• 69 Acute care hospitals
(14,072 beds)
• 96 Lo...
Catalan Healthcare System
U
S
E
R
U
S
E
R
SERVEI
CATALÀ
DE LA SALUT
100%
SERVEI
CATALÀ
DE LA SALUT
100%
SUPLEMENTARY
PRIVA...
An increasing number of elderly
Source: INE, projections 2011
1/3 of population will be over 65
and 12% will be over 80
3.5.1. Hospital beds per 1000 population, 2010 and
change between 2000 and 2010
2010 (or nearest year)
Germany
Austria
Hun...
Hospital discharges in OCDE countries
Source: OECD Health Data 2012; Eurostat
Database; WHO European Health For All Databa...
Source: Catalan Health Plan 2011-2015.
The Catalan Health Plan 2011-2015
Health Programs:
Better health and
quality
of lif...
Strategic lines of the program
• Integrated Care Pathways as a formal agreement among
professional clinical leaders at local level
• Based on reference c...
®
212 PHT
2 HOSPITAL
316
GROUPS
3191
PARTICIPANTS
233
EXPERT PATIENTS
649
PROFESSIONAL
OBSERVERS
EXPERT PATIENT PROGRAM 20...
®
METHODOLOGY
Source: Programa Pacient Expert ICS® 2006
Healthy
33%
Chronic non complex
62%
Complex
3,5%
Advanced
1,5% End of life Bereavement
PREVENTIVE APPROACH
CURATIVE APPROA...
Healthy
33%
Chronic non complex
62%
Complex
3,5%
Advanced
1,5% Terminal Bereavement
PREVENTIVE APPROACH
CURATIVE APPROACH
...
Healthy
33%
Chronic non complex
62%
Complex
3,5%
Advanced
1,5% End of life Bereavement
PREVENTIVE APPROACH
CURATIVE APPROA...
Taking care of complex patients
▪ Stratification model /predictive model
▪ Model of care for patients with complexity
▪ Pa...
19
Multimorbidity unified data base
Insured data source
NIA, demographic data
Diagnosis data base
NIA, tipus_codi, codi, d...
Multimorbidity in Catalonia
DM2
COPD
DEPRE
OSTEOARTHRITIS
Prevalence of comorbidity
Heart Failure
22
PCCMultimorbidity
Severe unique disease
Advanced frailty
MACALimited live prognosis
Palliative approach,
Advance care p...
-Care centres that have patients classified and marked in these two
types, can publish this label/mark in HC3
- The classi...
NUCLEAR CARE MODEL
IMPLEMENTATION SUPPORTING GUIDE
Source: PPAC 2013. Departament de Salut
NEW
INDIVIDUAL
ACTIONS
TEAM
RED...
Check list for support of deployment complexity care model
Basic and Priority: “PCC” and “MACA” identification and labelli...
Initial Health
Plan target(!):
25.000 complex
chronic patients
should be identified
by 2015
At April 2014
over 90.000
pati...
“Shared Individual Intervention Plan” (PIIC)
Health problems/Diagnosis
Active Medication
Allergies
Recommendations for...
Basic assessment in Complex Chronic Patients
• Basic standardized and customized assessment: Functional +
Cognitive impair...
A “NECPAL Questionnaire” is available to
assess “Advanced Chronic Disease” Condition
• “Surprise question” (!): “Would you...
“Clinician could create a Plan according chronic conditions
and related variables available to perform follow-up”
Level 2
Chronic patients at risk
Case
Management
Disease
Management
Self-care suport
Level 1
People with stable
chronic di...
32
Multimorbidity unified data base
Insured data source
NIA, demographic data
Diagnosis data base
NIA, tipus_codi, codi, d...
Clinical Risk Groups and levels of aggregation
Standard aggregation  1.000 groups (CRG) Aggregation in groups
In the stan...
Stratification and Emergency admission risk
CRG RSC
Identification
people at risc
Proactive
measures
Classification people...
How does it work the morbidity “grouper”
Population Grouper
Classification
(Stratification)
Intervention
Follow-up
CRG:
Cl...
Returning population stratified data base
Chronic disease selection
Hospitalization
s Risk
ID DM HF COPD Asthma Other: Nº
...
1% 18% 133% 10.992€ 13% 13%
2% 7% 57% 5.872€ 13% 26%
8% 3% 28% 3.162€ 28% 54%
17% 1% 14% 1.411€ 25% 79%
72% 0% 2% 282€ 21%...
Different utilization of Stratification
• To adjust models of “per capita” financing, assigning
different budget related t...
Visualization in Shared Clinical
Record and different RISK scores
Morbidity group
and RISK calculated
and published twice
...
CRG information
(morbidity group),
severity and
Hospitalization Risk
CRG information
(morbidity group),
severity and
Hospi...
PATIENT SELECTION by CRG + Nº emergency admissions
last 12 months + Hospitalization RISK next 12 months
Who are the PCC and MACA patients ?
Source: CatSalut, 2013
PCC MACA
Who are the PCC and MACA patients ?
Source: CatSalut, 2013
Distribution of emergency admissions
1 chronic
condition
2 chro...
Constructing a new “Morbidity Grouper” in
Catalonia: emergency admission distribution
Source: CatSalut, 2013
No urgent
hos...
Current situation chronic patient avaluation
Indicators Primary
Care
Hospital Care
Avoidable Hospital Admissions + -
Home ...
New evaluation vision: “Triple Aim”
Population
Health
Experience
of Care
Per Capita
Cost
• Health Outcomes
Indicators inco...
Trend in Quality
Measures: increasing
interest of
“Coordination Area”
New contract 2013: Common PHC-Hospital Targets
48
COMMON TRANSVERSAL OBJECTIVES(20%)
Reduction Avoidable Hospital Admissio...
Information System Tool for Managers
in Primary Health Care
Screen where you could monthly monitor health indicators
avail...
SISAP: Professionals System Information
Screen display of indicators by doctors and nurses. (!) Monthly
data updated !!! D...
List of patients
in bad control
Clinician could edit and print list of patients who could benefit of an
intervention for e...
HTA: TA good control
+1,6% last year variation
DM: Good metabolic control
+2,8% last year variation
Multidimensional assessment in Home Care
+4,4% last year variation
Heart Failure: patients treated with ACE
+0,8% last year variation
 HIS is progressing towards a patient-centered model
 It searches information collected earlier and available
in the sys...
Els agrupadors CRG grau/gravetat
CRG Morbidity Group
and number or previous
emergency admissions
“Individual”
proposal per...
WARNINGS and ALERTS
Discharge Planning / RX / Lab results
List of patients sorted by “gaps”
ID PACIENT “GAP”
Panel Management: Alert and Warnings screens
60
•It has been converted
information into warnings when
we access to clinica...
• Indicators of admissions for every Sector and Primary Health Team
• 14 chronic diseases
• Benchmarking with different st...
Hospital admission by diagnostic groups > 70 y.
Source: DGPRS. Dep Salut, 2013
COPD
HF
Urinary Infection
Asthma
Diabetes w...
Hospital admissions for ACSC
Monthly udpated information!
Includes: COPD, HF, pneumonia, DM complications, asthma, urinary...
Potentially avoidable hospital admissions for COPD
Decrease by 13,1 % from Dec 2011 to Dec 2013 (24 months)
Availability o...
Potentially avoidable hospital admissions for
heart failure
Source: MSIQ, CatSalut
Decrease by 3 % from Dec 2011 to Dec 20...
Differences in standarized Avoidable
emergency admissions in Spain
Source: Abadia MB. Atlas Variabilidad Hospitalizaciones...
Large differences in emergency hospital
admission rates by sector (x 100.000 inhab)
Catalan average: 971 x 100.000 inh.
Large differences in emergency hospital
admission rates by sector after adjustment
Differences in 30-day readmission rates by sector
Catalan average: 10,78%
Readmission rates by sector after adjustment
Heart Failure
COPD
Avoidable Emergency Admissions in ACSC
Available
information at
Primary Health
Care Centre level
Diabet...
30-day readmissions
90-day readmissions
30-day Readmissions per Heart Failure per Hospital area
Expected per capita expenditure
The 1% of top consumers spend 1.701,5M €, the 23%
of total cost with an average of 21.540€...
Expected per capita expenditure
Average expenditure (€)
Primary Care Pharmacy Emerg.adm. A&E Outpatient Clinics
AGE
Primar...
Basis for a Social and Health Integrated Care
Plan for Catalonia:
PIAISSPIAISS
Integrated Health
and Social Care
is high priority
and policy in
England
https://www.gov.uk/government/policies/making-sur...
Integrated Health and Social Care is high priority in
England: Integrated Care value case toolkit is developed
http://www....
Direcció d’Atenció Primària Costa de Ponent
Integrated Care Model and Social Services
Mrs
Smith in
Torbay
What does Mrs.Smith want?
25th
February 2014:
New Government Agreement
where is launched a new
Integrated Health and
Social Care Plan in Catalonia
A...
Catalonian Integrated Care model:
Set of elements support Integrated Care
Multi-lever approachMulti-lever approach: ALL th...
Emergency admissions tax related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x...
More than a half
emergency
admissions
compared to
Catalan average
(adjusted data)
Emergency admissions tax related to COPD...
Emergency admissions tax related to HF exacerbation
Almost half
emergency
admissions
compared to
Catalan average
(x 100.00...
More than a half
emergency
admissions
compared to
Catalan average
(adjusted data)
Emergency admissions tax related to HF e...
Emergency admissions tax related to diabetes complications
Almost half
emergency
admissions
compared to
Catalan average
(a...
How to conduct a collaborative model?
Local Operational Plan
Situation analysis (through SWOT analysis or any other method...
How to conduct a collaborative model?
1. Environmental and internal analysis at local level
Minimum internal and external ...
How to conduct a collaborative model?
5. Shared information systems: constructing a new eClinical
and Social care record
•...
North Ireland is
developing and
Integrated health and
social care record !!!
“PCC / MACA”
condition
Shared
Individual
Intervention
Plan (“PIIC”)
Diagnostics/
Health problems
“Dependency
degree” forma...
How to conduct a collaborative model?
6. Selection of people based on cross-database and lists of people
from social and h...
How to conduct a collaborative model?
11. Common and transverse Shared/Single Outcome
Framework with incentive alignment. ...
1. Structure: existence Local Functional Plan (LFP) containing a
minimum analysis of situation, action and evaluation prop...
ICT Strategy in
The Catalan HealthCareand SocialCare
System
ICT Services
TicSalut Foundation
Shared Electronic Health Record (eHR) end Personal
Health Folder (PHF)
iSIS.Cat. Integrating Health an...
TicSalut: Technology, Innovation & Health
Founded in 2006, TicSalut Foundation is an agency within the
Catalan Department ...
TicSalut, a responsibility to innovate
■ Advancing Knowledge Transfer in the Region
■ Providing an Innovation Observatory ...
97%97%
Hospitals
98%98%
Primary
Care
82%82%
Long-term
care
67%67%
Mental
health
Catalonia
Spain
USA
27 hospitals 6
EMRAM D...
Shared eHR and PHC
There are two key elements to develop ICT according to the
objectives of the Health plan:
Electronic He...
1.8m docs/month
23%
Current model
121.390 access/month
64%
New model
BPM
Rules
CDSS
IS
Web services
Care processes
Health ...
Shared Clinical Record (HCCC) to share among organizations
common clinical information: diagnoses, prescriptions, vaccinat...
Primary Care
Information from Centres/Hospitals
Specialist Care
Diagnostic
Procedures
Diagnostics
Prescriptions
Vaccinatio...
Folder
Information
Digital certificate
Documents
Channel
Communication
Robust password
Services
CITIZENS ACCES TO DATA
Home Diagnosis ePrescription Vaccination Connect My controlsReports
Search by:
- Report type
- Date
- Center
PHC: Clinical...
Online: always updated
Printable
PHC: ePrescription – Available and printable
medication and chronic treatment
Hom
e
Diagn...
Reported from provider
center
Reported from vaccination
book
Reported verbally from
patient
Duplicated
PHC: Vaccination an...
i-SISS.Cat
Strategic plan for the implementation and
deployment of the platform for the
management of healthcare and socia...
111
• Management of the different clinical processes included and
priorised in the Healthcare Plan
• To introduce real vir...
Courtesy of:
Mr. Jordi Martínez
Chief Innovation Officer, TicSalut Foundation
jmartinez@ticsalut.cat
gencat.cat
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Juan Carles Contel, Department of Health, The Journey from a Chronic Care Program toward an Integrated Health and Social Care Model

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The Journey from a Chronic Care Program toward an Integrated Health and Social Care Model
Speaker: Juan Carlos Contel Segura, Department of Health, Chronic Care Program, Generalitat de Catalunya (Catalonia)

Published in: Healthcare, Health & Medicine
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  • At the individual level this translates to good or better health , good experience and good value
  • In this slide you can see the points to be discussed during our presentation.We begin with a brief overview of the Catalan health care model. That explanation is necessary in order to understand how we are designing and implementing information systems in the healthcare environment in Catalonia.Then we will continue with an explanation of our organization, the Catalan Institute of Health.My colleague, Jordi, will explain you what is plan information systems in Catalonia.Finally we will explain two case studies we are doing in our organization.
  • Juan Carles Contel, Department of Health, The Journey from a Chronic Care Program toward an Integrated Health and Social Care Model

    1. 1. Basis for a Social and Health Integrated Care Plan for Catalonia: PIAISSPIAISS The journey from a Chronic Care Program towards a new model of Integrate health and social care
    2. 2. Session structure • A new Health Plan and the introduction of a new STORY • Chronicity Prevention and Care Program: the “journey” toward Integrated Care • Complex Chronic Care Program • Towards a new evaluation framework: The first results • A new journey toward a new Integrated health and social care model • ICT developments to support new Integrated Care model
    3. 3. The Spanish National Healthcare System • NHS funded by taxes • Decentralized to regional autonomies • Universal coverage • Free access • Very wide range of publicly covered services • Co-payment in pharmaceutical products • Services provided mainly in public facilities • Interterritorial Board to coordinate policies
    4. 4. Catalan Healthcare System: some basic features • Area: 32,106 km2 • Population: 7,611,711 inhabitants. 17% over 65 y. (expected 32% in 2050) • 1780 € expenditure per capita and 1150 € public expenditure per capita in 2012 • Life expectancy: 82.27 years • Gross Mortality rate (2010):8/1,000 inh. • Infant mortality (2010): 2.6 /1,000 live births • 369 Primary Health Centres (PHC) ranging from 20-45,000 inh) • 69 “acute hospitals” (no far from 50 Km. from every home) • 96 “long term care” centres (residential homes: long-stay, convalescence, pal.liative care) • 41 Mental Health Centres
    5. 5. Public System Network: • 369 Primary Care Teams (827 local health centers) • 69 Acute care hospitals (14,072 beds) • 96 Long-term care centers • 41 Mental health care centers Healthcare data figures
    6. 6. Catalan Healthcare System U S E R U S E R SERVEI CATALÀ DE LA SALUT 100% SERVEI CATALÀ DE LA SALUT 100% SUPLEMENTARY PRIVATE INSURERS 20% SUPLEMENTARY PRIVATE INSURERS 20% INSTITUT CATALÀ SALUT (public) 20% INSTITUT CATALÀ SALUT (public) 20% PRIVATE CENTERS 10% PRIVATE CENTERS 10% CONTRACTED NON-PROFIT PROVIDERS 70% CONTRACTED NON-PROFIT PROVIDERS 70% Commissioner Provision
    7. 7. An increasing number of elderly Source: INE, projections 2011 1/3 of population will be over 65 and 12% will be over 80
    8. 8. 3.5.1. Hospital beds per 1000 population, 2010 and change between 2000 and 2010 2010 (or nearest year) Germany Austria Hungary Czech R. Lithuania Poland Bulgaria Belgium France Slovak Republic Romania Finland Luxembourg Estonia Latvia EU-27 Greece Netherlands Slovenia Malta Cyprus Italy Denmark Portugal Spain Ireland United Kingdom Sweden Iceland Croatia Serbia Switzerland FYR of Macedonia Montenegro Norway Turkey Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health For All Database. Germany Austria Finland France Number of hospital beds in OCDE Spain EU-27 United Kingdom Sweden
    9. 9. Hospital discharges in OCDE countries Source: OECD Health Data 2012; Eurostat Database; WHO European Health For All Database.
    10. 10. Source: Catalan Health Plan 2011-2015. The Catalan Health Plan 2011-2015 Health Programs: Better health and quality of life for everyone Health Programs: Better health and quality of life for everyone Transformation of the care models: better quality, accessibility and safety in health procedures Transformation of the care models: better quality, accessibility and safety in health procedures Modernisation of the organisational models: a more solid and sustainable health system Modernisation of the organisational models: a more solid and sustainable health system I II III For each line of action, a series of strategic projects will be developed, which make up the 31 strategic projects of the Health Plan. For each line of action, a series of strategic projects will be developed, which make up the 31 strategic projects of the Health Plan. 9. Improvements to information, transparency and evaluation 1. Objectives and health programs 7. Incorporation of professional and clinical knowledge 6. New model for contracting health care 5. Greater focus on the patients and families 8. Improvement of the government and participation in the system 2. System more oriente d towards chronic patients 3. A more responsive system from the first levels 4. System with better quality in high-level specialties
    11. 11. Strategic lines of the program
    12. 12. • Integrated Care Pathways as a formal agreement among professional clinical leaders at local level • Based on reference clinical guidelines and best evidence practice • Critical key points identification • Critical variables uploaded at Shared Clinical record • 80% of territories implemented 3 of 4 chronic conditions: COPD, depression, heart failure and DM2. Now Complex Cronic Care Pathways work • Agreement on different “situations”: 0. Diagnosis, 1. Stable, 2. Acute exacerbation, 3. Management difficulty, 4. Transitional Care • Other 6 conditions to be included in the future 12 Integrated Care Pathways
    13. 13. ® 212 PHT 2 HOSPITAL 316 GROUPS 3191 PARTICIPANTS 233 EXPERT PATIENTS 649 PROFESSIONAL OBSERVERS EXPERT PATIENT PROGRAM 2006-2013 Source: Programa Paciente Experto Catalunya® 2013
    14. 14. ® METHODOLOGY Source: Programa Pacient Expert ICS® 2006
    15. 15. Healthy 33% Chronic non complex 62% Complex 3,5% Advanced 1,5% End of life Bereavement PREVENTIVE APPROACH CURATIVE APPROACH PALLIATIVE APPROACH SELFCARE COLLABORATIVE CARE The continuum of chronicity
    16. 16. Healthy 33% Chronic non complex 62% Complex 3,5% Advanced 1,5% Terminal Bereavement PREVENTIVE APPROACH CURATIVE APPROACH PALLIATIVE APPROACH SELFCARE COLLABORATIVE CARE Integrated Clinical and Care Pathways
    17. 17. Healthy 33% Chronic non complex 62% Complex 3,5% Advanced 1,5% End of life Bereavement PREVENTIVE APPROACH CURATIVE APPROACH PALLIATIVE APPROACH SELFCARE COLLABORATIVE CARE Taking care of complex patients
    18. 18. Taking care of complex patients ▪ Stratification model /predictive model ▪ Model of care for patients with complexity ▪ Palliative care-oriented model in persons with advanced chronic disease ▪ Collaborative model between health services and social services: integrated health and social care
    19. 19. 19 Multimorbidity unified data base Insured data source NIA, demographic data Diagnosis data base NIA, tipus_codi, codi, data dx ,UP, tipus_UP “Contact” data base NIA, dates contacte ,UP, tipus_UP, urgent, CatSalut, T_act. MDS-Hospital MDS-PHC MDS-MH MDS-NH MDS-A&E Central Registered Insured Health Problems Pharmacy (PHC and hospital provided) Pharmacy data base NIA, ATC, data dispensació, unitats, Import Mortalitat (INE) Data sources Divisió d’Anàlisi de la Demanda i de l’Activitat
    20. 20. Multimorbidity in Catalonia
    21. 21. DM2 COPD DEPRE OSTEOARTHRITIS Prevalence of comorbidity Heart Failure
    22. 22. 22 PCCMultimorbidity Severe unique disease Advanced frailty MACALimited live prognosis Palliative approach, Advance care planning Two profiles of complexity
    23. 23. -Care centres that have patients classified and marked in these two types, can publish this label/mark in HC3 - The classification / label must be visible on all the screens , given the importance of the condition - It has been incorporated in July 2013 version to HC3 stratification with Clinical Risk Groups (CRGs) PCC: Complex Chronic Patient MACA: Advanced chronic disease
    24. 24. NUCLEAR CARE MODEL IMPLEMENTATION SUPPORTING GUIDE Source: PPAC 2013. Departament de Salut NEW INDIVIDUAL ACTIONS TEAM REDESIGN TERRITORY COMPLEXITY CARE PATHWAY Basic requirements Optimal provision Excellence
    25. 25. Check list for support of deployment complexity care model Basic and Priority: “PCC” and “MACA” identification and labelling + Integrated Care Pathway + 24 / 7 model + Carer identification and support
    26. 26. Initial Health Plan target(!): 25.000 complex chronic patients should be identified by 2015 At April 2014 over 90.000 patients included Evolution of PCC / MACA with a collaborative intervention plan in shared IT “Labeling” available since January 2013 !
    27. 27. “Shared Individual Intervention Plan” (PIIC) Health problems/Diagnosis Active Medication Allergies Recommendations for “in case of crisis” or exacerbation Advanced Care Planning Resources and services used Multidimensional assessment Carer whom are delegated decisions Additional information of interest
    28. 28. Basic assessment in Complex Chronic Patients • Basic standardized and customized assessment: Functional + Cognitive impairment + Social Risk + Depression • NECPAL assessment to identify “Advanced Chronic Disease” condition • Complementary assessment
    29. 29. A “NECPAL Questionnaire” is available to assess “Advanced Chronic Disease” Condition • “Surprise question” (!): “Would you (the referee clinician) be surprised that patient could die in the next following 12-18 months?” • Al least another clinical condition indicating bad prognosis
    30. 30. “Clinician could create a Plan according chronic conditions and related variables available to perform follow-up”
    31. 31. Level 2 Chronic patients at risk Case Management Disease Management Self-care suport Level 1 People with stable chronic diseases at early stage Level 3 Complex chronic patients Comorbidity, emergency hospitalizations, A&E visits, moderate and severe dependency, polypharmacy HEALTH PROMOTION Healthy people WHO do we like to identify people at risk?
    32. 32. 32 Multimorbidity unified data base Insured data source NIA, demographic data Diagnosis data base NIA, tipus_codi, codi, data dx ,UP, tipus_UP “Contact” data base NIA, dates contacte ,UP, tipus_UP, urgent, CatSalut, T_act. MDS-Hospital MDS-PHC MDS-MH MDS-NH MDS-A&E Central Registered Insured Health Problems Pharmacy (PHC and hospital provided) Pharmacy data base NIA, ATC, data dispensació, unitats, Import Mortalitat (INE) Data sources Divisió d’Anàlisi de la Demanda i de l’Activitat
    33. 33. Clinical Risk Groups and levels of aggregation Standard aggregation  1.000 groups (CRG) Aggregation in groups In the standard aggregation (health status, basic CRG and level of severity) we obtain a basic information about health status and level of severity in less than 40 groups HealthStatus Severity Level Status 9 Status 8 Status 7 Status 6 Status 5 Status 4 Status 3 Status 2 Status 1 1 2 3 4 5 6 More than 1,000 groups. Too much !!!
    34. 34. Stratification and Emergency admission risk CRG RSC Identification people at risc Proactive measures Classification people at risk Segmentation for the proactive management of people at risk Identification and recording at Clinical Record
    35. 35. How does it work the morbidity “grouper” Population Grouper Classification (Stratification) Intervention Follow-up CRG: Clinical Risk Group Risk Adjustment per morbidity IdentificationKey conceptsKey concepts
    36. 36. Returning population stratified data base Chronic disease selection Hospitalization s Risk ID DM HF COPD Asthma Other: Nº emerg admis ssion Hospital Cumulat ive days CRG (status and severity) Hospitaliz ation Tax Mortality Tax ZAGO234… 1 1 0 0 1 3 18 7.4 80% 40% ROGU675.. 1 0 1 0 1 1 8 7.3 65% 28%  Selection of patients by different criteria  Different pyramids related to different Risk approach: Future hospitalization / Death / Future cost
    37. 37. 1% 18% 133% 10.992€ 13% 13% 2% 7% 57% 5.872€ 13% 26% 8% 3% 28% 3.162€ 28% 54% 17% 1% 14% 1.411€ 25% 79% 72% 0% 2% 282€ 21% 100% POPULATION MORTALITY TAX HOSPITALI- ZATION TAX ESTIMATED EXPENSE % ACCUMU- LATED Impact distribution of different segments
    38. 38. Different utilization of Stratification • To adjust models of “per capita” financing, assigning different budget related to morbidity burden in each PHC • To identify populations and population segments with higher multimorbidity burden and more RISK of.........................: Emergency hospital admission High Cost High pharmacy consumption High mortality Higher Social Services Utilization • To assign “individual” RISK: not yet well calculated, we need more variables to be included and should accept limitation of these tools • How to incorporate Stratification scores into Information Systems: Visualization and access to Shared Clinical Record and local clinical record Return of data base to local providers • Validated model in American population or an own national/regional model ?
    39. 39. Visualization in Shared Clinical Record and different RISK scores Morbidity group and RISK calculated and published twice a year Description of different RISK segments
    40. 40. CRG information (morbidity group), severity and Hospitalization Risk CRG information (morbidity group), severity and Hospitalization Risk • CRG 7/5 • 3 emergency admissions • Hospitalization Risk of 35% PCC/MACAPCC/MACA Included in “CASE MANAGEMENT” Program Included in “CASE MANAGEMENT” Program CRG and Risk score visualization
    41. 41. PATIENT SELECTION by CRG + Nº emergency admissions last 12 months + Hospitalization RISK next 12 months
    42. 42. Who are the PCC and MACA patients ? Source: CatSalut, 2013 PCC MACA
    43. 43. Who are the PCC and MACA patients ? Source: CatSalut, 2013 Distribution of emergency admissions 1 chronic condition 2 chronic conditions 3 chronic c. Cancer Other high demanding c.
    44. 44. Constructing a new “Morbidity Grouper” in Catalonia: emergency admission distribution Source: CatSalut, 2013 No urgent hospitalization
    45. 45. Current situation chronic patient avaluation Indicators Primary Care Hospital Care Avoidable Hospital Admissions + - Home Care program Coverage + - Health outcomes: good control, process and treatment ++ - Readmission rate in chronic processes: Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure (HF) - ++ COPD/HF Avoidable Hospital Admission - - Discharge planning in “PRE-Discharge” program - + To ensure continuity care in “POST- Discharge” program + - “Quality of life” (HRQoL) assessment - - Fragmented care and fragmented evaluation framework
    46. 46. New evaluation vision: “Triple Aim” Population Health Experience of Care Per Capita Cost • Health Outcomes Indicators incorporates in evaluation Primary Health Care (PHC) (good control chronic diseases, vaccination..) • Quality of life • Satisfaction • PROM • Costs • Service utilization: Avoidable Hospitalizations , Readmissions,… Evaluation and commissioning of ”Integrated Care” ?
    47. 47. Trend in Quality Measures: increasing interest of “Coordination Area”
    48. 48. New contract 2013: Common PHC-Hospital Targets 48 COMMON TRANSVERSAL OBJECTIVES(20%) Reduction Avoidable Hospital Admissions Rate (composite, HF and COPD) Reduction 30-day Readmission Rate for HF and COPD (also composite) Get minimum value prescription pharmaceutical index % minimum discharges with contact before 48 hours after discharge % minimum register screening risk factors Metabolic syndrome TMS ESPECIFIC TRANSVERSE OBJECTIVES (“TERRITORY”) (20%) % minimum PCC/MACA with Intervention Plan (“PIIC”) % minimum PCC/MACA with medication review % minimum PCC/MACA with post-discharge medication conciliation Reduction emergency admissions in PCC/MACA Minimum number participants Expert Patient Program % minimum COPD patients with spirometry % minimum PHC with Mental Health integration Prevalence minimum depresion with “severity” criteria % minimum patients with depresion with “suicide risk” assessment Development at local level a consultant virtual office “Amputation rate” reduction in DM “Ophthalmology/locomotor “ referral first visits under expected tax
    49. 49. Information System Tool for Managers in Primary Health Care Screen where you could monthly monitor health indicators available for Primary Care managers
    50. 50. SISAP: Professionals System Information Screen display of indicators by doctors and nurses. (!) Monthly data updated !!! Differentiated internal weight among indicators You MUST identify an expected prevalence Comparison with Team and all organization
    51. 51. List of patients in bad control Clinician could edit and print list of patients who could benefit of an intervention for every health indicator to act proactively Information System Tool for GPs and Community Nurses in Primary Health Care
    52. 52. HTA: TA good control +1,6% last year variation
    53. 53. DM: Good metabolic control +2,8% last year variation
    54. 54. Multidimensional assessment in Home Care +4,4% last year variation
    55. 55. Heart Failure: patients treated with ACE +0,8% last year variation
    56. 56.  HIS is progressing towards a patient-centered model  It searches information collected earlier and available in the system  It proposes actions related to the current conditions and multimorbidity profile  It is a tool to facilitate prevention, diagnosis and follow-up to deal with long-term conditions  It is a part of a whole and integral follow-up model “Inteligència Activa” (Active Intelligence)
    57. 57. Els agrupadors CRG grau/gravetat CRG Morbidity Group and number or previous emergency admissions “Individual” proposal per patient, created assessing needs of each patient All patient information with a click: Clinical follow-up, / Lab and other test results / Clinical Guidelines / Vaccinations / Terapeuthical guidelines / Diagnosis / Morbidity Groups,... “Inteligència Activa” (Active Intelligence)
    58. 58. WARNINGS and ALERTS Discharge Planning / RX / Lab results
    59. 59. List of patients sorted by “gaps” ID PACIENT “GAP”
    60. 60. Panel Management: Alert and Warnings screens 60 •It has been converted information into warnings when we access to clinical record in each visit •Customized configuration per professional and Team •Warnings sorted by importance and relevance •Weekly calculation (“online” proposal) •“Front-office” and “back office” modality Mean 20-30% improvement in some scores !
    61. 61. • Indicators of admissions for every Sector and Primary Health Team • 14 chronic diseases • Benchmarking with different standards among PHT and Hospitals Servei Català Salut. División de Registros MSIQ. Quality measures MSIQ: http://146.219.25.61/msiq/index.html
    62. 62. Hospital admission by diagnostic groups > 70 y. Source: DGPRS. Dep Salut, 2013 COPD HF Urinary Infection Asthma Diabetes with complications
    63. 63. Hospital admissions for ACSC Monthly udpated information! Includes: COPD, HF, pneumonia, DM complications, asthma, urinary infections, dehidratation, HTA Availability of evolution of avoidable emergency admissions for ACSC per region / sector / PHC team (x 100.000 inhab. Tax) Source: MSIQ, Catsalut −6,5 % last 24 months
    64. 64. Potentially avoidable hospital admissions for COPD Decrease by 13,1 % from Dec 2011 to Dec 2013 (24 months) Availability of evolution of avoidable emergency admissions per region / sector / PHC team (x 100.000 inhab. Tax) Source: MSIQ, Catsalut
    65. 65. Potentially avoidable hospital admissions for heart failure Source: MSIQ, CatSalut Decrease by 3 % from Dec 2011 to Dec 2013 (24 months) Availability of evolution of Avoidable Emergency admissions per Region / Sector / PHC Team (x 100.000 inhab. Tax) New trend! Increase by 25% from 2006 till 2011
    66. 66. Differences in standarized Avoidable emergency admissions in Spain Source: Abadia MB. Atlas Variabilidad Hospitalizaciones Potencialmente evitables, 2011 COPD HEART FAILURE
    67. 67. Large differences in emergency hospital admission rates by sector (x 100.000 inhab) Catalan average: 971 x 100.000 inh.
    68. 68. Large differences in emergency hospital admission rates by sector after adjustment
    69. 69. Differences in 30-day readmission rates by sector Catalan average: 10,78%
    70. 70. Readmission rates by sector after adjustment
    71. 71. Heart Failure COPD Avoidable Emergency Admissions in ACSC Available information at Primary Health Care Centre level Diabetes complications Asthma Accessible by Primary Care Directors
    72. 72. 30-day readmissions 90-day readmissions 30-day Readmissions per Heart Failure per Hospital area
    73. 73. Expected per capita expenditure The 1% of top consumers spend 1.701,5M €, the 23% of total cost with an average of 21.540€ per cápita cost The 5% of top consumers, spend 3.783,6M €, 51% of total cost with an average of 9.580€ per cápita cost Average expenditure (€) Percentiles related to expenditure
    74. 74. Expected per capita expenditure Average expenditure (€) Primary Care Pharmacy Emerg.adm. A&E Outpatient Clinics AGE Primary Care Pharmacy Emergency admissions Outpatients clinics
    75. 75. Basis for a Social and Health Integrated Care Plan for Catalonia: PIAISSPIAISS
    76. 76. Integrated Health and Social Care is high priority and policy in England https://www.gov.uk/government/policies/making-sure-health-and-social-care-services-work-together
    77. 77. Integrated Health and Social Care is high priority in England: Integrated Care value case toolkit is developed http://www.local.gov.uk/web/guest/health/-/journal_content/56/10180/4060433/ARTICLE
    78. 78. Direcció d’Atenció Primària Costa de Ponent
    79. 79. Integrated Care Model and Social Services Mrs Smith in Torbay
    80. 80. What does Mrs.Smith want?
    81. 81. 25th February 2014: New Government Agreement where is launched a new Integrated Health and Social Care Plan in Catalonia Accountable and reporting to Department of Presidency
    82. 82. Catalonian Integrated Care model: Set of elements support Integrated Care Multi-lever approachMulti-lever approach: ALL things at the same time: ALL things at the same time Integrated Care pathway: •Multiprofessional work around Primary Care •Care Transitions •Residential Care •24/7 model Joint Assessment + Joint Intervention Plan Stratification: assessing population needs Clinical and professional leadership Governance: Health and Social care Boards Shared Outcome Framework and joint accountability Aligned Incentives and Integrated Commissioning Shared clinical and social care record Culture and change management Self-care ENABLERS
    83. 83. Emergency admissions tax related to COPD exacerbation More than a half emergency admissions compared to Catalan average (x 100.000 inhab. Tax)
    84. 84. More than a half emergency admissions compared to Catalan average (adjusted data) Emergency admissions tax related to COPD exacerbation
    85. 85. Emergency admissions tax related to HF exacerbation Almost half emergency admissions compared to Catalan average (x 100.000 inhab. Tax)
    86. 86. More than a half emergency admissions compared to Catalan average (adjusted data) Emergency admissions tax related to HF exacerbation
    87. 87. Emergency admissions tax related to diabetes complications Almost half emergency admissions compared to Catalan average (adjusted) (x 100.000 inhab. Tax)
    88. 88. How to conduct a collaborative model? Local Operational Plan Situation analysis (through SWOT analysis or any other methodology for analysing): starting point, barriers, facilitators, opportunities and threats. External and internal analysis. Planning: defining an action plan, operational objectives, action lines and operationalized and calendarized actions. Communication and implementation: risk analysis tools as well as control and monitoring tools will be used, transversal implementation considerations such as quality, communication, training will be taken into account. Assessment: the project’s assessment and monitoring model, as well as participating agents’ responsibilities, assessment commissions and reports to be created should be defined.
    89. 89. How to conduct a collaborative model? 1. Environmental and internal analysis at local level Minimum internal and external situation analysis / Identify critical elements enabling the building of proposals to be collected in ‘Local Operational and Functional Plan’ (LFP) / Highly operational guidance and implementability with short terms results. 2. Integrated operational care model Operational approach promoting common space and time. 3. Define and use a “territorial governance board” Strategic governing body / steering group / implementing group 4. Define a common porfolio for people/users Complex Chronic care and dependence / Home nursing and home help service (SAD) / Hospital discharge planning / Institutionalized people / Mental health / Childhood at-risk / Abuse / Active aging, health promotion and disease prevention / Other
    90. 90. How to conduct a collaborative model? 5. Shared information systems: constructing a new eClinical and Social care record •Identify the person with the CIP (Identification Number) as a common identifier. •Prior agreement on the coding and register of social problems. •Prepare the local social services information system for it to be ‘interoperable’ in a short-medium term and provide a minimum set of information and variables for a Shared Social and Clinical Record •Access to a minimum set of information and variables of common interest on social field for the Shared Clinical Record of Catalonia (HCCC). Later stage: HCSC fed with input from both health and social parties. 1st stage: generation of a Social Intervention Plan incorporated to HCSC. 2nd stage: Shared Individual Intervention Plan. •Communication systems to improve accessibility, messaging and virtual work between social and health areas. •Introduce social variables gradually to available health stratification.
    91. 91. North Ireland is developing and Integrated health and social care record !!!
    92. 92. “PCC / MACA” condition Shared Individual Intervention Plan (“PIIC”) Diagnostics/ Health problems “Dependency degree” formal assessment “Home Help” services label “Telecare” services label Social Care Intervention Plan Pharmacy prescription Health CareHealth Care Social CareSocial Care + Social “Health and Social” Integrated eCare Pilot project in pioneer territories
    93. 93. How to conduct a collaborative model? 6. Selection of people based on cross-database and lists of people from social and health areas and stratification (!!!) 7. Definition of guaranteed protected pathways in transitions (discharge planning + post discharge support) among services and in crisis situation and proactive planning. 8. Dependence assessment and recognition procedure optimized with a guaranteed maximum response time. 9. Incorporation and definition of roles and responsibilities of different professional profiles (esp. Social workers working in PHC 10. Accountable professional reference for complex cases.
    94. 94. How to conduct a collaborative model? 11. Common and transverse Shared/Single Outcome Framework with incentive alignment. Progressive process. Triple aim vision: health results and good care, service utilization and good perception of care. 12. Definition and implementation of an integrated home care model. 13. Joint action plan for promoting autonomy, active aging, health and well being and disease prevention incorporating the role and collaboration of telecare services. 13. Accessibility solutions and joint technical assistance home aids stores from a territorial perspective. 14. Incorporation of the third sector. 95
    95. 95. 1. Structure: existence Local Functional Plan (LFP) containing a minimum analysis of situation, action and evaluation proposals 2. Accessibility: time access to Social Services and Primary Health Care 3. Activity:  Minimum number or coverage of users or people attended jointly by evaluation year  Minimum number of coordination meetings structured and planned annually 4. Satisfaction of users when covered by program together. Quality of Life assessment 5. Professional Satisfaction 6. Service Utilization: Avoidable potentially hospitalizations in chronic diseases, 30-day readmissions,… Looking for a Shared Outcome Framework to promote Integrated Care with Social Services
    96. 96. ICT Strategy in The Catalan HealthCareand SocialCare System ICT Services
    97. 97. TicSalut Foundation Shared Electronic Health Record (eHR) end Personal Health Folder (PHF) iSIS.Cat. Integrating Health and Social Care 1 2 3
    98. 98. TicSalut: Technology, Innovation & Health Founded in 2006, TicSalut Foundation is an agency within the Catalan Department of Health that works to promote the development and use of ICT in the health and social care domain, acts as a trends, innovations and emerging initiatives observatory, and provides services for the standardisation and accreditation of products.
    99. 99. TicSalut, a responsibility to innovate ■ Advancing Knowledge Transfer in the Region ■ Providing an Innovation Observatory in the HealthCare domain ■ Standardizing Interoperability ■ Managing the demand for Innovation across the whole HealthCare system ■ Promoting Innovation in HealthCare
    100. 100. 97%97% Hospitals 98%98% Primary Care 82%82% Long-term care 67%67% Mental health Catalonia Spain USA 27 hospitals 6 EMRAM December 2013 Current Situation in December 2013
    101. 101. Shared eHR and PHC There are two key elements to develop ICT according to the objectives of the Health plan: Electronic Health Record of Catalonia (eHR) Personal Health Channel • It allows organized access to relevant information of different centers health records and to some central databases of the health system. • The eHR is not the sum of the electronic records of the healthcare centers; it doesn’t incorporate all the information from medical records. • The citizen is the holder of the data contained in its medical record • He will have access to its health information available in its electronic Health Record As an information and services network Deployment of a multichannel network to communicate and interact with the citizen
    102. 102. 1.8m docs/month 23% Current model 121.390 access/month 64% New model BPM Rules CDSS IS Web services Care processes Health intelligence Messaging platform BI/visor Future model: ISISS.cat Health and social integration Healthcare processes integration Challenging EVOLUTION
    103. 103. Shared Clinical Record (HCCC) to share among organizations common clinical information: diagnoses, prescriptions, vaccinations, hospital discharge reports,...
    104. 104. Primary Care Information from Centres/Hospitals Specialist Care Diagnostic Procedures Diagnostics Prescriptions Vaccination Hospital Discharge Report A&E Report Specialist Care Report Lab Results RX Report Other diagnostic reports Hospital Data Information from Dep of Health Electronic Prescription Diagnoses Procedures Discharge Data Prescription Medication Plan Shared Clinical Record (HC3)
    105. 105. Folder Information Digital certificate Documents Channel Communication Robust password Services CITIZENS ACCES TO DATA
    106. 106. Home Diagnosis ePrescription Vaccination Connect My controlsReports Search by: - Report type - Date - Center PHC: Clinical reports
    107. 107. Online: always updated Printable PHC: ePrescription – Available and printable medication and chronic treatment Hom e Diagnosis ePrescription Vaccination Connect My controls Report s
    108. 108. Reported from provider center Reported from vaccination book Reported verbally from patient Duplicated PHC: Vaccination and Reports vaccines supplied Hom e Diagnosis ePrescription Vaccination Connect My controls Report s
    109. 109. i-SISS.Cat Strategic plan for the implementation and deployment of the platform for the management of healthcare and social care Processes in Catalonia
    110. 110. 111 • Management of the different clinical processes included and priorised in the Healthcare Plan • To introduce real virtual work substituting face-to-face work • To assure interoperability between different providers, unifying the model of integration and information sharing • To share data and construct processes with Social Care provision • To measure ”directly” the relevant indicators established within the Health Plan and Catalan Outcome Framework • To share with the patient and citizen the management of his/her health The i-SISS.Cat solution should allow:
    111. 111. Courtesy of: Mr. Jordi Martínez Chief Innovation Officer, TicSalut Foundation jmartinez@ticsalut.cat
    112. 112. gencat.cat

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