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Josep Roca. Gestión hospitalaria en tiempos de crisis

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Josep Roca. Gestión hospitalaria en tiempos de crisis

  1. 1. Estrategias para la adopción de nuevasprestaciones de servicios para pacientes crónicos La experiencia del Hospital Clínico de Barcelona Josep Roca Hospital Clinic.IDIBAPS.University of Barcelona
  2. 2. Health system redesign
  3. 3. INTEROPERABILITY AMONG PROVIDERS • Level A - Barcelona – Esquerra • Level B - Spain and Europe Patient summary record and electronic prescriptionBARCELONA ESQUERRA • 540.000 habitantesEAPs ICSEAPsCAPSE • 18 ABS y 2 CAPs II (5 empresas EAP Gesclínic distintas) EAP LesHortes 5D EAPsVallplasa HospitalClínic • 4 Hospitales 5E HospitalSagratCor 4CClínica Plató 4B 5C 5B • 1 Centro Sociosanitario principal y 5A 4ACAP II Manso (ICS) 3E 3G 2C 2E otros de menor dimensión CAP IINumància(ICS) 2B 2D 3D 2A 3B • 3 Proveedores de Salud Mental 3A 3C • Servicio de Emergencias Médicas de Cataluña
  4. 4. Deployment at Barcelona Esquerra 2009: Territorial Health Care Comission Barcelona Esquerra Institutions Permanent Comission representative Technical Implementation Management Redesign & follow-up TeamProcess 1 Specialized Care Mental health Pediatric care Health Transport Pharmacy Home Care EmergenciesProcess 2 Social Care ITProcess 3Process 4 Operational Committees
  5. 5. Deployment at Barcelona Esquerra 2009: Hospitals vs territorial healthcare Community HOSPITAL Care FamilyProcess Units Transplant Physician Nurse Dementia Social COPD Territorial Worker Healthcare Home CHF Care
  6. 6. Deployment at Barcelona EsquerraThe Vision
  7. 7. STRUCTURES RELEVANT TO CONTINUITY OF CARE IN CHRONIC RESPIRATORY PATIENTSINTEGRATED HEALTH SECTOR BARCELONA-ESQUERRA (AISBE) CHRONIC CARE UNIT LINKCARE HEALTH SERVICES S.L. CLINICAL INSTITUTES
  8. 8. Integrated Care Strategies for Chronic Patients - enhanced citizens life style - well standardized care paths Modulation of disease progress Efficient patient management
  9. 9. Service model• Target patients• Management by programs• Well standardized interventions• Patient-centered care providers network Support Patient center Personal Health Folder • Triage • Self-management • Remote monitoring
  10. 10. INTERVENTIONSHOME HOSPITALIZATIONPREVENTION OF HOSPITALIZATIONSHOME MONITORINGHOME REHABILITATIONHIGH QUALITY SPIROMETRY IN PRIMARY CARE
  11. 11. Activity organized by care programs including clusters of diseases Cardiovascular Respiratory Diabetes - Obesity Fragile patients
  12. 12. Deployment and Adoption 2010-2012
  13. 13. Current Deployment atBarcelona Esquerra (Nexes) Wellness & Rehabilitation Frailty - Transitional care - Palliative care Home hospitalisation Support
  14. 14. Need for operational definitions of frailty and identification of associated servicesSystem-related factors Patient-related factors Scenario Organizational model Socio-demographic Integrated care strategies with ICT support Professional & health care Chronic conditions resources Treatment & self management Health & Social resources Dependency Quality of life Satisfaction & self-efficacy information
  15. 15. Assignment level of complexity (frailty) VERY LOW LOW COMPLEXITY HIGH COMPLEXITY COMPLEXITY in addition, they show some of the following factors Patients with 1. More than two co-morbid conditions and Charlson 1. High hospitalization rate in the none of these index > 2 previous year (> 2 admissions factors 2. High score of anxiety/depression (HAD > 6) including emergency room visits) 3. Home bound being alone at home for more than 2. Tertiary level therapy at home (non- 50% of the day invasive mechanical ventilation, 4. Home bound with a caregiver of similar age etc…) 5. Treatment adherence assessed by Morinsky- 3. End-stage complex disease Greens (> 4 different pills/day) 6. Oxygen therapy 7. Need of social support 8. Need of low complexity home care services (wound cures)
  16. 16. Emergency room Hospital specialized units Day care / Home hospitalization Eligibility assessment of all patients (+ 40 years old) admitted because of exacerbation of COPD + other respiratory diseases Not eligible (EXCLUSION CRITERIA) Accepted to participate Inability to use the ICT Eligible (INCLUSION CRITERIA) Living in the area equipment (patient and Informed consent caregiver) Yes No Advanced cancer Patient assessment . Assignment level of complexity (frailty group) Number of participants who do Very low Low High not accept to participate and their reasons are recordedBaseline measurements Randomization CURRENT CARE Training/Installation INTERVENTION CURRENT CARE AT THE PARTICIPATING HOSPITAL Very low Low High Follow-up measurements
  17. 17. Tailored intervention by level of complexity (frailty) COMPLEXIT VERY LOW LOW COMPLEXITY HIGH COMPLEXITY1. Education of self-management including co-morbidities (pharmacological/non-pharmacological therapies) and elaboration of personalized action plan2. Access to the call centre3. Access to personal health folder4. Visit at home within 72 h including primary care team and social support team5. Video-conference during 1 week6. Remote sensors monitoring (defined on individual basis by the specialists)7. Remote questionnaire monitoring8. Home-based rehabilitation (physiotherapists and/or occupational therapists)9. Connection with convalescence centre (if needed)10. Video-conference up to 1 month (defined on individual basis by thespecialists)11. Additional remote sensors (defined on individual basis by thespecialists)12. Remote support of the specialists including home or day hospital visitwhen needed
  18. 18. ROADMAPWe should develop the potential to be at the forefront of healthcare delivery innovationby embracing the evolution of medicine and technology The 4 P’s of Medicine: System Predictive Medicine Personalized Preventive Participatory 2020 Personal Health Services Evolved Integrated Care Services 2011 Use of technology

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